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May 16 03 02: 18p RI^HWRIN LAW 20" 956 4010 p. 3 <br /> 05/16/2003 12:02 20946 18 AGE STOCKTON PAGE ��3 <br /> SAN SOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIR00t4'rTAL BLUTH DIVISION <br /> SITE MITIGATION MAST£RFILS RECORD PORM <br /> Ga NERAL PROGRAM FILE: New Qiangc Edit iPRO04) revised :/21/94 <br /> s <br /> FACILITY 1D I FACILIT_' NAK / <br /> RECORD ID M PRIOR CIST p PRIOR SwSsps p <br /> Site Mitigataow nvj,ronmGslcak Anaesament T/CAP oral Hazardoua Waste Invest arrtac Pipet•>", Invest <br /> they lcaC Agency Sit, envy: NQCB DT9C EPA A Site deer Quality Stee char 11,P. 91te <br /> DESIGNATED 6*1PLOYEE q PROGRAM ELEMENT & Z�5� C1JRRRNT STATUS ..R <br /> VUM = OF UNITS : EPA ID b: /� jmftCTJON coat <br /> .Aunber of TANKS linked to this PROGRAM record <br /> 9xj.LIHG ACHNOULE00>?1�NT: 1, tke =ndeesigned owner, operator or agent of some, acknowledge that all Site and/or oxe7ec: soecif:c <br /> PHS-04D hourly charge: associated with thin fatil:cy or activity will be balled to the party lden"l ied as the RILLINI 9juTY on <br /> LnO lMaaterfIle Record Infocmetion form. <br /> I also cercaRy that t have prepared thin app ttion and that the work to be performed will be done in accordance wit; all SAN <br /> 30AMIN COUNTY Ordinance Codes end 9tanda tate and Federal lava. <br /> V APPLIGANT'S,SIGNATURE __—_ <br /> Dates <br /> AU1210RI7ATIOM XO RkLEA56 IRFORnWYSON� In addition to the above, wnen applicable, 1, the ower, operator or agent of Ikm". of <br /> the property located at the above ecce addrean hereby authorize the .release of any and all results. eeoteenn'Ical data unUor <br /> environmental/rite aeseenmenc information to SAN JOAWIN COUNTY PUBLIC HEALTH SERV14=6 ENVIRONMENTAL REALV DIVISION .00n as <br /> it is available and at rho game time it Se provided to ee or my representative. <br /> DWLINE DATES; InsPcc%'On: Current Prior <br /> pee Amount amount Paid (late of Payment Payment Dy. I Recaipc. 0 Check 9 Recv iy <br />