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03/27/2003 07: 47 916-786 366 LFR PAGE 03/03 <br /> D3/21/2003 11:51 4648 ENVIR"ENTALOLTH PAGE 02 <br /> SAN TmhQuzs CoGNTY P=4c KMTH SERvr=s <br /> �NIRONmENTAL HEALTH DIvISION <br /> SITS TY.TICATTGN MASTSREIL£ RECORD FM <br /> .ENEHAL PRCORAM FILL: NCW ClfanEe Zd1t / ^p (PP=4) revised 5/23/94 <br /> FACSLSTS" SD :I FACTLITV NAM Y TRAC-Y1 TM F►EE• 51-re- <br /> MOR <br /> 1TE <br /> R£CDRD zD # PRIOR DIST 0 PRIOR SUEZ S S <br /> its NSCigAeian: X 'lYlxanmeACa1 .las•sament ST/GAP cal tamrdeus Naaee T_rn�eac a Pip�li.e Smx_ac <br /> Crier Lead Agency SAte eney, C9 PT-9c SpA p4 54pa rater QuASiCy Sine Chez Type sive <br /> OESIGNnTED SMPLAYEE X y'T ! PHaGw�M ELECEN'f .Y LryV CT]F9IIu1' a6""4.:G5 <br /> a2"m OF M= 1 EPA m y: SNSPHC:TDN CDD£ : <br /> ,;umbar of L4MC5 IAT%ked to this rsrnrd <br /> BILLING AMOHLEI rmmm: :. tris under igned owne Aerator or agent of same. ncknowledga Char all site and/ar,prajeet apodias <br /> RHs-M�D hourly charges Araaelaeed I s Saa1}Aty or 0.eCi'vitY NA11 4^. hillyd Ce she party ideElkiCied as the HSLLSNG TART` an <br /> the Masterfile Racord information Form, <br /> I also cert`-iy Chat S have Arepared this application and that the work to Ce performed will he done in accordance Nith all SAN <br /> ,/ J011p1IIN couNtT ordtnanoe C.dss And standards, $tare And °cdcrml Lava. <br /> APPLICANT'SSS3iGNATORE <br /> Ylela: ✓f 1� I R•v/wl JV/f4V/1Cx r Dot., v~ ~O? <br /> ACMRIZATiCN To 4Ei,PaGR fNFORMULON: Yr. addiCion to the a,, whee applicable, :. the owner• aperator or agent of sane. of <br /> the property located at the above site Addread harmby a"horieo the rHlaase at amr and sit results, geoteoheieal data and/or <br /> enviro va6htal/sits esaeammant infarmacian to SAS SOWIS COUNTS PUBLIC rMLTH SERVICES EIWIAANPfS = MM!M DNIarns as aeon as <br /> it is available and At [he game time it is provided Co m,e or my rern9enCeCLve. <br /> gCADLS.NH bAI63: I+t'1peaCion: oo:rent ! ! Prior <br /> Fee Ar.unt <br /> AMCMIt paid D-C* a; Payment Payment T/pa R"Cipe M CJfaak X arevd 3y <br />