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SAL`) jOAQVIm C xwv. iKmuC =nTH SERv IC=S <br /> mvIRCfU1E1TM REALTH DIVISION ' <br /> ^Ji!' MIT_IGATI(= NASTMUFMLE itECMW aORM <br /> GWERA. PROGRAM !ILa: (VROG4) :rviscd S/23/94 <br /> di. <br /> 1 L.0 CVP.. O. 1-4644 <br /> eACI:.i?Y ID p FACII.I4 t :ZAt� � <br /> PE''ORD ID y PRIOR DiS`_ E PRIOR SdEMMPS 4 <br /> its NsL=SaCiOfi: +�l-"O"TCt7LSI Assess <br /> :/CAP cal Haxardmus �tasmt Invest -a-Ha� JGS-ZG r^vr.ac <br /> cher Lead Agency [ <br /> Sice cT.c+: u �C EPA PL Site arer Quality Site cher Type Site T <br /> DESYGNM:D _"PLOYEE {0 /�� PRCGRAtt STAiJS <br /> NL-,.mE1 o? UNITS 1 1 c'A ID a: 21SPEC•=GN CODE <br /> Vum5er of TANK'S linked to this 7ROGRM record": <br /> SI: .IVG AC.Q�O�:+rDGCf :I: I, the urzcrsiy ed owner, ooerator Jr ayer_t of same, ack==ovicdge that ali site anal/or proicct spccific <br /> Dns-EZ) hourly charges a33ociaccd with t.`113 :acilicy or activity will be billed to the ?arty idenci_ied as the BILLING PAR-17 on <br /> he Masterfile Record Information Form. <br /> I also ceri`y :hat I !Zavo ysegared c5i3 apglicacioa a-d chAr the *ork to be per-formed -ill be done in accordance with all SAI <br /> ,OAQUi: COLM- f Ordinance Codes and Standards, State and Federal laws. <br /> APPLIVI1M4- IA-MIE v <br /> a <br /> Title- Dace• <br /> A .-H0P.-T7A':0K TO RFLFlSz iNF04I+1TION: I.} addition to the abo-C. 'emn applicable, I, the owner, operator or agenr of same, of <br /> cte Property located at t'.se above site address hereby authori=e cho release of.any and all rasulta,' geocechnical data and/or <br /> environmental/site asseszmer_c i:formaciam to SAN j0AQLi9 =67Y PM=C 1MnTH SERVICES ENVIRC1R&TIAL MUIL=d DIvlz!CN :: 7con a3 <br /> is is available and ac the same t.ne is is provided co me or my repreaentacive. <br /> DEADLILP£ DA=S: I-spcetio.% Crrenc / / prior / ! <br /> r-ee :..noun: Ancount laid rCace of ?ayme=:c Payment :ype Receipt # C:eck p Recvd By <br />