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04/10/2001 08:25 2094683433 FIFTH FLOOR PAGE 02 <br /> n, <br /> � <br /> SAN JOAQI7TN COLI= PTMLIC RFALT14 SERVZ <br /> �EC� �� <br /> EPTVTROrUCNTAZ. M]3 LTR DIVISION <br /> SITE MITICAT:ON MASTERF= RECORD FORM PR 10 2001 <br /> ` Cham3e Edi= 4�ROG <br /> New ¢) revised 5/23/94 <br /> GENERAL ?RoQRAM FILE: <br /> �Jw / S auyh Ct>P e�' a/u 64 <br /> FACILITY IA # 1� FACrL'T% NANL Go�1 ,� �a�/�/ <br /> RECCRO 11) w n�/ PRIOR DIST PRIOR SWEEPS 0 <br /> Site Mitigationsnmental Assesament ST/CAP al Razardouz- waste invest �az&at Pipeline invest <br /> Cher Lead Agency Site PAjency: WQC3 DISC EPA L Site scar Quality Site ther Type Site <br /> --FDESIG7ATED EMPLOYEE q / PROMAM EL MENT # 1 G� CO2RENT ST�ITIIS <br /> N91+ID&R OF GL']ITS : <br /> SPA ID #: p L tVU! IDTsPECTICN C=E <br /> Number of TALARS linked to this ppj)M2AK record <br /> 6ILL=W ACM4OwLZDGEMEN1': I. the ursdersigned owner, operator or agent of same, acknQwladge that all sztc ark/ar PrOSect specific <br /> PHS-EHD hourly charges a SoC±Ar-� with this facility or activity will be billed to the party identi=fed as the BILLING P �' on <br /> the Masterfile Record information Form. <br /> also certify that I have prcparcd Cl%ia application and ChaC the uazx to be performed will be done in accordance with all SAN <br /> JrAQUZN ca= ordinance Codes and Standards, State and pedera laws. <br /> APPI-1=4T'S SI=AT(7RE , <br /> Title- <br /> A=ORIZATICN To RELEASE INMP 4ATION: In addition to the above, when applicable, 1, the owner, oPerator or agent O£ game, of <br /> the property locaCod at the above 7iCe adds Hereby authorize Lte release of any and a.11 results, geotec'sn'_cal data and/or <br /> environmental/site assessment information to SAN S'CACuIN Cou= PUBLIC FMALM EN <br /> SERVICES VIRONMEYTAL ECEAL.63 DIVISION as soon as <br /> it is available and at the same time it is provided to me or my repreaontative. <br /> DEADLINE DATES! Inspection: CuenC /�� Prior <br /> Fce Amount Amount Paid Date of Paymenc Payment Type Receipt # Check 2eavd Sy <br /> c% lS9 lie- <br /> y/ylo/ <br />