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ti'�¢/Zl/2003 11:51 4640138 <br /> ENVIRONMENTAVALTH <br /> PAGE 02 <br /> SAN JOAQUIN COUNTY MBLIC FMALTN SERVICSS <br /> F.NVIROWGZ?rAL REALTg DIVISION <br /> SIT$ tixT:CATION MASTSRFILE RECORD FORM <br /> :i uVSRAL PROGRAM FILE: <br /> New Change edit <br /> FACILITY ID % o FAC:�:TY NAME e <br /> fPROGa) revised /23/9, <br /> ✓TR,�c <br /> RECORD ID ; Y Tilee r GIEE <br /> SATE <br /> P-0sa�3 S'D eaxDR Dlsr q <br /> PRIOR SWEEPS s <br /> ite Mitigation: <br /> StbMlental Asaesamenc 5T/CAP <br /> cal Raznrdevr ace Zb .. <br /> Cher Lead =4&Z Pipeline :m.est <br /> AgsnCY Site envy: WQl3 <br /> DTSC EPA L SiN <br /> ater Quality site Cher <br /> '4'pe site <br /> DFSIIRRATED EMPfAYFE q L q / PRCC;MM Ej.E ANT % <br /> c9.4• b0 =mEvT sTATGS <br /> YfAIDER OF CHITS <br /> � EPA ID q; <br /> INsPSC^ION CODE <br /> Number of rANRS linked to chi, FROM M raeord C �-3 l <br /> J <br /> BILLLNG ACWCNLEDGEMENT; I, the undersigned owner, operator or agent of same, +rknerledge ti+ec all site and/ar prpj ect sp*elfie <br /> PRS-EHD hourly cnarges associated with this faeiliey of activiCY will N billed ee the art at allfle <br /> the MasCerfi:e Record Ln±ormation Foran, party d as the BILLING PART" an <br /> [ also Ccteily chat I have prepared Chis appliraeton and that the work to be terformed will be done in accordance with all SAN <br /> JOACUIN COUNT'! ordinance Codes and Eenndarda, Stat* and Federal Ass. <br /> APPLICANT'S SIGNATZ29tVA60—� OaC07 <br /> ride: ✓M -2S—o3 <br /> AUTHORIZATION :0 RELEASE n;rQRMtTICK! In addition to the above, when Applicable, I. the owner, operator or agent of same, of <br /> the property located at the shove aite address hereby Authcria* the release of any and 411 re,ulta, geotechnical data and/or <br /> environmental/site AssesBUcZ iftfd r tion to SAN TOA=lf COUNTY PUBLIC X"TH SERVX=S ENVIRONMENTAL REALM DIVISION ab 'no, as <br /> it is avaixaa{c and At the same time it is provided to me or my repreamtacive. <br /> DEADLINE MAIM Inspection: LLrrent / / Prior T, / <br /> Fee Aaounc Amount Paid Date of Payment payment Type Receipt 4 Cheek % Rec,,d 3y IHv 97 <br />