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9-10-1998 10:28AM FROM n n P. 2 <br /> .SAN JMAQ= COUNri' POSLIC HSW= SRR.VICES <br /> ErramamL MMLTE DIVLSION <br /> SITE K=GATIOM NAStb'RW= RECORD FORM (f <br /> 2j) W. K.R-tth o,`"t a <br /> LD <br /> GMAT. vPAC'tTM FILE: Neti�man9e Edit (PROG4) revised 5/23/94 <br /> �xcZ-y m p •="-•,• me To KM SHE U <br /> RECORD 'ID x PRIOR Dwr R PRTOR SNEEP'' p <br /> site Mitigation: 1 Assesenrnt /CAP 1 e•_a.w^us paste Ta esc t Pipeline imcst <br /> eller Lead Ae= y Site DFSC EPA Slte atez Quality Site cher 'type Site <br /> DFSI=TED ENPIOYEE x �I 2 "e11 p t Circe <br /> NM,CM OF UNTLS : 1 EPA ID p: =PEC:IDN CODE <br /> Nwnber of MQW linked to this PR XM M M—rd <br /> S=Z cur ACI"MEDGEHEpT: I, the undersigned sac, opecetor o-_ agent of some, acksawledgo tw+C all site and/or Project spec_fic <br /> PHS_00 Dourly c➢u9es associated tiro chi, facility or activity Will be billed em the petty Silent'=led as the BT.,.L37G PART! on <br /> the msterfile Record Sntormecion Form. <br /> a13e certify ZUC I ba" prcpnred Ibis appliracan and coat the work to be pez!ormed will ba Qooe in accordance vitt all SAN <br /> JOAQDIN CM= Ordir� Codes and Standards. S <br /> tate and Federal lard. <br /> APPLICAs1"S s.GIUTmzR : i`�'M WQ-�-- O✓� behzA j 0F L�y i hrn &iuy(5c'S L-C- <br /> Title: Ce�lariI + C'zvnbr)� L11Vi1 OYlmc�tl2� Data: 9 -Z4 -98 <br /> ADTRORIFATION TO R=-'%= INFO@pTION: In addition to the abo , rt n appliCable, I, chc owner. operator or agent of same. of <br /> the property lamtod ac the above site address herby anrhocise the rvkwsa of any and all resin". geotechnical data snd/or <br /> aavirvomesral/site asseeseane information. to SAN JOACOIN CDONTI P=XC REA[.TR SERVICES �= DIVI.'TON as soon as <br /> it is available and at the sane e5me is is provided to ee or my representative. <br /> DEADI,ZCE DATE: Inapetti=: Cuxrmt <br /> Fee(Amount Amami Paid Date of Payment Payment Type Receipt xmeek x AccvC ey <br />