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e r 20'd 1tit01 some <br /> tJIIV� <br /> • SAH JOAQUIN COUNty PUBLIC HEALTk SERVICES <br /> ENVMOMaNTAL REAL79 DIVTSI(v <br /> SITS MITIGATION MASTSRFILE RECORD FORM <br /> GENERAL PROGRAM PIIS: HeW Chaa9e.,�,_BCIC <br /> (pROGa) revised 5/23/m <br /> FACILITY IDM FACILITY HAPm n <br /> A A41C <br /> RECORD ID tt ��— PRIOR DIST 4 PRIOR SWEEPS �1 <br /> 4 <br /> Site Mitigation: viranmental Asseaament /CAP Wcal HaaArdous Waste Inveat 2Ma <br /> Eftpelioo- Invent <br /> then Lead Agency SiCc ency: 4CB DTSC .EPA L Bite ater Quality Sitepe Site <br /> DESIGNATED EMPIAYEE -V0 1 PROGA.AM pUSMEtJ7 I �v! GCURRSHT STA= <br /> =-MER OP UNITS <br /> RPA In M: ' [[ ✓ =PECTION CWF <br /> NLVber of TANKS linked to this PROGRAM record <br /> 811-r- NG : I, the undersigned Owner, operator or agent of same, acknaaledge that all site and/or project specific <br /> PHS-EFS hourly charges associated With this facility or aCtivity will be billed to the party Identified as the BrLL,ING pARTy on <br /> 'the Masterfile Record Information Form_ <br /> PAYMENT <br /> I also testify that I have prepared this application anB that the work to be performed will be done in accordarnce�Fttr131E <br /> JOAQUIN COUNTY Ordinance Codes and Standards. State and Federal law&, 1 <br /> AUG 2 5 1995 <br /> APPLICANT'S SIGNATURE : SUSLI JOA(1U[rVCOLI,Y <br /> } EN C HEALTH S ICES <br /> Title: <br /> �LG� �G?�1.�.- HEAITH D,VIS1Qn: <br /> Date <br /> .UfHORIZATIOH TO RPJ-tME INFQRMATZOH; In addition to the above, when apylicable, I, the owner, operator or agent of same, of <br /> the progeny located at the dbove site address hereby aur the release of any and all results, geoCeetsnical data and/or <br /> environmental/site dssaasment information to SAN JOAQUIN COUNTY KMLIC HEALTH SERVICES EHVIRONMMcTAI, HSAL,R DIvISION as soon Ag- <br /> it is availablt and at the same time it is Provided to me or my representative. <br /> DEADLINE OATES. inspection: Current <br /> /— /_— Prior <br /> Pec AmOtult t Paid �^•` <br /> Date of Payment PaYmcnL Type Receipt R Check a Recud by <br /> :7 A,1 c� X30 7J' <br /> z0'8 01 W08J Wd60:20 S66I-£z-80 <br />