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<4 L <br /> May 16 03 02: 18p RISHWAIN LAW 209 956 4010 p. 3 <br /> 05/16/2003 12:02 2094671118 AGE STOCKTON PAGE •33 <br /> SAN SOAQUIN COUNTY PUBLIC HEALTH 51IRVTCES <br /> ETNIXg$Nr.'1TAL HEALTH DIVISION <br /> SITE MI'T'IGATION MASTERFILS RECORD POW <br /> GvWRAL PROGRM FILE: New Qtansc arc (PROW revised :/21/94 <br /> ?AGILITY :D y I"' 7 <br /> 4 7 la <br /> ZECORD ID I 1 p ] PRIOR DIST 0 PRIOR SAPS a — <br /> ate Mi[lgdtaon' % <br /> vy,ro vntncal ?Jeaasmant ST/CAD ocal NarardOua Waste Invelc adut Pipelin, Invest <br /> Cher Lead Agency Sacc envy: No DT9C EPA A sate aver Quality Slee than L'pe Sica <br /> PROGRAM Fr a*�ir a Z�V� C.7RRIIrC STA'IC14 <br /> 3ESIGi4ATED -PLOYES 4LEI <br /> EPA ID p: Ii(d*=TjoN COOS <br /> .qUm&R OF UNITS <br /> Vumber of TANKS linked to Chia 4ROGRAM record <br /> S c 310 <br /> BILLING ACIMwLf0 D' N^: I, toe undersigned owner, operator or agent of same. acknowledge ehac 811 Site and/or Pro3ec. siecif:c <br /> PHS-£KD hourly charges associated with this facility or ac-"pity Will be balled to the party 1denG:.11ed as the BILLING PA1TY on <br /> the Mascerflle Record Infocmatlan Form. <br /> I also cert>gy that I hsws Prepared this app scion and chat the work to be performed +aI1 be done in accordance wit: 811 5AP <br /> 30AQUIN COUNTY Ordinance Codes and Standa tact and Federal lava. <br /> Ey APPLICANT'S,SIGNA[URR — — <br /> �'Tit1e: Va <br /> AUTHORIZATION TO R}.LKA.'iS IN of In addition to the above. •hen applicable. I. the sines, opet'atoecnnlagent <br /> data'uu, of <br /> the property located at the above site address hereby sucharize the Keeleass LTf{ES A�IC�K aE1N�17I8D� �� DIVISION ,. .goon as <br /> edvironmental/site aase8ement i�nformatidn td SAH JOAQUTN COUNTY re PUBLIC <br /> HMive. <br /> it is AvAiiabld and at she same time is is provided to me Or COY Pr <br /> DWLINE DATES: Inapcccioot cuizenc <br /> Prior <br /> Amount Yaid Ogee sf Payment Payment a Reearpc. M <br /> Qwectc A Fsecv: �Y <br /> Fee Amd%mc <br /> -e, 75 <br /> `L2 <br />