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PROGRAM ELEM NT: 3(� <br /> DBA: •�" PHONE: qpu— lqfl <br /> ADDRESS: i 1 CITY: <br /> Designated Operator: ;b. PHONE: <br /> OWNER: ,/ ' d r. <br /> PHONE:j2l) S , <br /> ADDRESS: y �• ��N <br /> BILLING ADDRESS: <br /> } CONTACT: <br /> PHONE: <br /> ADDRESS: <br /> APN: IN vhtv LOT SIZE: SHORT TERM: APCD PERMIT: <br /> r WATER PURVEYOR: + SANITARY-DISTRICT: <br /> FACILITY TYPE:_NulmlV001 SEPTIC: WELL: <br /> TYPE 1 2 3 4 5 TYPE 1 w1.2 3 4 5 -TYPE 1 2- 3 4 5 TYPE 1 2 '3 4 5 <br /> ` TANK: I TANK: ?/ TANK: TANK: <br /> STATE ID: STATE ID:.' STATE ID: STATE ID: <br /> PRODUCT: PRODUCT: PRODUCT: PRODUCT: <br /> � I <br /> SIZE: 15_�� SIZE: <—oy SIZE: SIZE: <br /> PIPING: T PIPING: PIPING: PIPING: <br /> > <br /> i� <br /> MONITOR: MONITOR:;: MONITOR: MONITOR: <br /> i <br /> I} at <br /> IE1 i <br /> .y y, <br /> 6 f 4 t< N A I Y T I �' � l •sot! <br /> •Water <br /> h, •Hazardous Waste i <br /> Richard Sereno <br /> oaaugAssurance i <br /> • (2U9 572-0900. ± <br /> (zoo 572 tis FAx <br /> l4 Kansas Avenue <br /> '. Modesto,CA 95351 <br /> t <br /> B <br /> ti <br /> Ra <br /> fQ <br /> R <br /> 1 <br /> l R <br /> STAT057TifiEo <br /> ECEA <br /> Field Sampling 1 Envirnnmeryta!Testing <br />