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8—*1?,121005 09:41 30946830 EHD • PAGE 02 <br /> Suer JOACUZN COUNTY POBLIC AI.�3 sERviCES <br /> r; Vnt0NMMN'ral. x I� DI+rzsForr <br /> SITE MIT.SGATrQN MMTZRPJLZ REC©RD FORM <br /> Edit (PRwA) revised S/33/94 <br /> GENERAL P80CRAM FILS: <br /> ff[RIEECO <br /> D 1 1-� IL03 bACITY NAi+3 rPRIOR1S4R SNEEBS 4D <br /> I <br /> lee Mitigat 4n <br /> visonmantCa3 Assessment ST/CAP al Hazardous Waste lavest &=Mat Pipeline Invest <br /> za <br /> icr 6�" <br /> t: Lead Agency Site <br /> 9iQCE =SC SPA L Site aces Quality Sir-* her Type Site <br /> PROGlL9M EF.priPsrC G, CIIRRENT STATfSS <br /> Di[7mER OF =TS �� <br /> EPA ID a, INSPE=t.11 CODE <br /> '.+UTbox of TANYS linked to this PROGRAM zecord :T — <br /> wner, operator or age= 4£ same, acknowledge Chat all site and/or project specific <br /> BILLING ACI4IOWLEDGElSBNT: I• t uadersigned othe SII.L� PARTY on <br /> pkS-EM izoutlY charges asaocit►Ced :with this facility or activity will be billed to the party identified as <br /> the Masterfile Record Information 70rm. <br /> I also certify that I have prepared rhis applicyZion and that the work to He eerformed will be dobe in accordance w;.M all SAN <br /> .-OAQWIT couNTY Ordizu=* Codes and Standards, tate and Fc1ftxal laws_ <br /> APPLICANT'S SIGNATURE <br /> %,, <br /> Date: / <br /> Title' 1/ "v "W <br /> AT.=RZ=10l4 TO RELEASE nuORMATION= In additien Ca toe above, when applicable, I, the owner, aper"OK Or agent of same' of <br /> the property located AC the above site ,address hereby authGri%* Che release of any and all results, geotach=Wl data and/or <br /> snsrirgAmentallaite aaacasmKnt information to SAN JCAOTM COUNTY MBLIC HEALTH =VICES MMON ENTAL RBALTH DSV'SION as soon aC <br /> it is available and at the same t5.me it is grrn+ided ea me or my ropresanestive_ <br /> LN <br /> MlY� <br /> DEADLE DATES. I-sPecrion: C�xrect T_/� �/ Prior <br /> Fee Amount Amount Paid <br /> Data of Payment payment Type Receipt # Check # Recvd. By <br /> ou <br />