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IU 1J10JGOJJ41 r.nc <br /> I SAN JOAQUIR COUNTY PUBLIC NEP.LTTT SZRVICEE <br /> i ENVIRO"NTAL HEALTH DIVISION <br /> - SITS MITIGATION MASTERFILR RECORD FORM <br /> t <br /> i <br /> GENERAL PROOPAF9 PILB: NeW Change Sdit <br /> I (PACV'9) revised 5/23/94 <br /> j <br /> FACILLTY ID >Y I EAZII NAME I >0�� _ I� <br /> I I <br /> RaCV�lD YD ♦ J G%1 PRIOR DIST f PRIOR SwErPS 4 j <br /> I <br /> site Mitigation: �gviremlrntal I!asesamaet T/CAP cal Razardous waste Iwest t Pipeline invest <br /> II i i <br /> ter Dead W7attay Sit OCB DISC EPA Site sitz Quality 51Ge . Cher Type Site <br /> I <br /> f j <br /> R^^^^ I <br /> DESLdttATED M IJWI PROGRAM ELEMENT N CIRUi&YT STATI)S . <br /> 17t1I�IBEk <br /> OF <br /> UNIT EPA ID Rt ' LNSR_'Ct IOv CODE I_ _ <br /> Numbek of TANAR linked t this PROGRAM record i <br /> r 1 <br /> i <br /> ILLIR9 ACTGIO SDOEMENT: 1, the undersigned owBar, operator or agent of same, acknowledge chs! All site and/or project specific <br /> •EHD hourly lchargea as oclated with this fat lity or activity will be billed to the party identified <br /> 0lr,� skCom�r►y <br /> i Tosco <br /> also l certify tFlat I prepared this appliCJtion and that the work to be performed will be done in accerdancei with all SAN <br /> 007F COUNTY 16dyuanea odes and Standards, Slur* and Pedasal laws. <br /> i <br /> PLI I 9 32C>�A'1[11t6 ILot <br /> t <br /> 'Pitlalr <br /> 1 I Date i . <br /> j <br /> L�d <br /> ADTMOR+zaTION , LSASE NPORMATI019e In addit>;on to the ahovl, when applicable. I, rhe owner, operaeer er agaot'df sane, ea <br /> prdpszty loiat a above 'site address hereby authorize the rele840 of any and all results, gootachnical decd and/or <br /> 1 wim�aental/j:d <br /> eases enc infoiTtlaCioa CO Sia JOAOtIIIs COUNTY PUBLIC AFALffi SERVI('83 ENVIAO <br /> tt 'I N:WC7IAL HEm DIVISTOW an soon as <br /> t is fVailabl .:att name tinesI it is provided to int or my representative. <br /> i . <br /> WDLINR DATest Ihs"ec OitaPrtCr <br /> Current � I <br /> Pae Amowyt . <br /> i Paid Datt Of Payment Pnym¢nc Type Repeipt a Check p <br /> Raavd By <br /> i ' D <br />