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A JOAOOIR COMM PUBLIC HEALTH SERVICES <br /> as✓ MW1R0E mml' RMALTR DIVISiow <br /> SITE HITIOATION MSTMILK RMCORD rORm <br /> Uaa307 <br /> CSNSM PROGRAM PILE, N•w N Q:iII9a Bdit IPROG4I raviaad 5/77/94 <br /> PACILITY ID 0 <br /> '05" <br /> PACTLiTI $Are <br /> "Cc" ID 1 PRIOR DIST M PRIOR SWEEPS 0 <br /> its Mitigation, ra,amintal Aseammaat PSTICAP ✓ cal Ramrdow waste Im"t t Pipeline Invest <br /> tber Lead Agency Site arMuy: oTsc CPA PL Site Ater poa.lity Site r Type Slt• <br /> DESIGEATRD We ayBE 0 PROGRAM ELEMENT 1 p Q CURRENT STATUS <br /> RUMMER oP UNITS t EPA 0 p, J IwSPRCTICN CODs , p�OCD <br /> Number of TANKS linked to this PROMAH record i <br /> BILL11M ACXN0WLZD0iMP17r: S. the underrigoed owner, operator or agent of ease, Acktgwledge that all site Sadler project specific <br /> PHE-®m hourly ebaages associated rich this facility or Activity will be billed to the party identified aJ the BILLING PARTY on <br /> the Meawrfile Reea"d Inforpstlon Poral. <br /> t also certify that I have prwpatad this application and that the work to be performed will be done JA aecoreanea eith all SAN <br /> /�J](���'���}�}y' C=rm Ordinance Codec and SWldsa�r/da. State and Pederal lava. <br /> E A PlZc'ST'R SIdwATMC <br /> IV <br /> Manager, Development & Operations <br /> riel•: Environment, Health, Safety &EnvironIDent, Health, Safety ToxicologX Dare, July 24, 1995 <br /> AUIHORIMT10H TO RSLMS INPORMaTIONt la addition to one above, when applleatla, 1, the owner, operator or agent of mane, of <br /> the property located at the above pies address hereby authorize the release of any Sad all "volts, geoteeknioal data and/or <br /> •Mwisoopenwl/site "OOM00e0t i OMOtian 40 SAN JOAOUIN COUNTY PUBLIC RERUN SSAVICBS 2N1RDZP0wT'ALD Isw ALLA37 . HSM,TR DIVISICw as noon as <br /> it is available and at the pens came it L provided to ee or Wy reprem,,otmti,ro, <br /> DENDIMKWI IIM UA=W: Inspaeeieq, cortsnt / / Prior <br /> Pas Mount •mount Paid Late of Payment Payment Type Raceipt R Cha a Recvd By <br /> '71 l 4r rA- 0Yl 146 <br /> TOTAL P.02 <br />