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Site Mitigation 04 <br /> Site Name/Add ess: 9 <br /> Site Code ` Correspondence Copies: F <br /> APN Microfiche <br /> Program element Binder(s) <br /> 4!5-. <br /> Trip Miles 436 <br /> Location Code 99 &71711 <br /> / WELLS <br /> < onsite offsite <br /> PUB/PART Date <br /> P �ntact: MWSJC <br /> EXTR <br /> CVRWQCB/TSCD EPA Contact: VW <br /> AIR <br /> CON ULTANT• / SPARGE <br /> - e � Other <br /> �'`� SZZ • C�l�(lac WES <br /> Domestic <br /> SIC C <br /> -�... Enterprise Zone <br /> Account ID AR0025513 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TRIPLEX RENTAL (Circle One) <br /> Account Balance as of 3/24/2004: $0.00 <br /> (Circle Onej <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 3030-UI CONTROL PROG SITE PR0521963 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt"�'� <br />