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SEP 13 '96 15:16 FR RSPI LEGRL ENVIRO 801 961 5596 TO 915109753412 P.02/04 <br /> pp, 6 (03 T'Y • S1W JDPNBI. <br /> pVIN COM P�IIC H== 36fi S <br /> C, S"V=5WWMy ELTN DNISION <br /> II{�VVOLO 203 ✓T2— SITE MITIWTION MWTWILB P=RD FM <br /> C04 RAL PROGRAM FILE: Nev Y, Marve Bdic <br /> [PROGeI servlaed 5/71/9q <br /> FACILITY ID N PACILTTY NAPM <br /> RECORD DO R PRIOR DISI tl PIlIOR SVCDt9 q <br /> it* Mitigation: omm�ncal ASS st"nt T/CAPJZPAff <br /> ffst� Q"Iity <br /> pipeline <br /> [her Lead Ageney Site aucye NOCB DTSC Isitt <br /> y DESICBMTED EZVU=B q ��. lJ.FJEaTT a CORIEFLI3' S <br /> G1_ NOrOEA OF UMTS EPA ID r: ZNSP&C?ION CQDB <br /> Number of TAws linkod to this PROGUM record <br /> BILLING ACjWOwLBDG0CM: I, the undersigned o"or. operator or ageot of same, aelaevledge chat all. site end/or projoec spcciClc <br /> PNS-ERD hourly chergca associated with this Facility or activity w111 be billed to the party identified a& the BILLING PARTY on <br /> the Masterfile Revoad Information Por,. <br /> I also eartify that I have Propared chis applieotion and that the work to be Performed will be dons in acoordaaco wish all SAN <br /> JOAQ= COUNTY Ordiaaaae Codes a0d Standatdo, State .sod Federal laws. <br /> APPLICANf S SIGNATM <br /> Title: L„Q EC.fbYi - L&LAL hFPRIR� <br /> AUTSORIZA7ION To RELSASS INFORMATION, In addition cepp <br /> the above, when applicable. I, the over, oPcracor or agent of same, of <br /> the Pe P=ty located at the above site address hereby authorize the release of any and all reculcs, 9cOt0c1n1cal darn and/or <br /> enviromental/site ascesssebt infdrm tlon to SAN JOAOUIN COUNTY PUBLIC NSALIA sMViCSS LwIRCMCXrAL NBALIA DFvTSICN An soon as <br /> i[ La available and At the same tine it is provided to mo or my repreeescacive. <br /> DBADLINQ DAIS, Inspection: Current / / Prior <br /> Pea Mount Amount PAid Date of Payment Paynonc Type Receipt q Check q Recvd By <br /> 23 L{ - <br /> SEP 13 '96 14:51 510 975 3412 PRGE.03 <br />