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JUL-24-1995 09:29 FMC EHS c �c <br /> - JOAGVIN COUFFY PUBLIC nALTH SERVICES <br /> MVIRONMEMAI, KALIF DIVISION <br /> SITE saria TION HaSTERiLL RECORD FORM <br /> CZW"AL PROGRAM PILE, N... V L cIhaape Edit -Too, 012 30 <br /> y(PRDCaI revised 5/17191 <br /> FACILITY = a -r//�7ACTLITY t1Af@ <br /> RICORD ID 1 .y Jv�/ / F PRICR DISI M PRICK SWEEPS C <br /> ice Mitigation. -irenswneal Aaeaefi ec /CAP cal Namardo" Note TImant t PIP*lina invest <br /> cher Lead agency Site .noy: DISC EPA PL Site ater U,AGity sit• r Type Sioa <br /> DRSIOWSH) 1IP16YRR R PROORnH ELEMENT * L �I_1 CUAJiQNr gIA'FUg <br /> �SR OF AHTS : EPA ID s, O INSPECTION CODE , <br /> Number of LWKS linked to thin PROCGM record <br /> BILLING ICRAQWGBDaVVt?F: I, the undersigned ow *r, operator or agent of lana. ackrgvledg9 that all site sac(/or project speelfic <br /> Pus-Gam hourly charge* associated with Chir facility or activity vill ba billed to the party identified 41 the BILLING PARTY on <br /> the Mmaterfile Record WorwaCLOn FOm. <br /> I alae cartify that I hAvo pr.par.d this application and that t1Ga .ark to be perfare.ed will bm dont in aCeoraa m with all SAR <br /> couYm Ozdir ace Cod" and standdarr1dc State and Federal lave. <br /> ]IPPLICMVV S 91ONATVRii I. 1h,,—1 <br /> IV <br /> Manager, Development & Operations <br /> Tielr. Environment, Health, Safety & Toxicology Bac., July 24, 1995 <br /> AUMRI2ATZON To RSLWWfl INFORF0nC Rt Ll addition to one abevn, uhtn ApplieAblt, 1, Cha ower, operator or agent of as", of <br /> the property located at the abowt a1C% addreas herehy suthorire the release of any sad All "suits, geotechnical data and/or <br /> sevironmental/site aatt*am.nt information to SAN JOAOvIN CCArrY "LIC HFALIH SERVICES RNVIcINMENTAL HEALTH DIVISION sa soon as <br /> Le i* aV.ilabl. Shd at tda was time it iA provided to me or my repse:,a„rat ivo. <br /> DRA)=XR VAT09: Inspaetion, CUazsnt �� / Prior / / <br /> Pta Amount Amm)ount(�Paid pate of Payment Paymone Type Racsipt R Ch.ek a Aeevd By <br /> C <br /> CONFIDENTIAL <br /> TOTAL P.02 <br />