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ADXQ= COMM PGBLIC WEALTH SERVICES . <br /> QA,IRGr34JJlTAL HEALTH DIVISla <br /> SIT! WaT=T1ON mxs= iLr RECORD FORM <br /> GST,EAAL PROGRAM TILE: New Qfaago Adie (PUGal revised 5/27/94 <br /> PACILITY In a FACILITY KVR <br /> WORD IDM PRIOR DLSI M PRIOR A7IF3P8 i <br /> its Mitigation, rceeencal As"Ument /CAP Saaardoue waata Invest klmmt Pipeline Invaac <br /> cher Lead Ageaey site enry: �Oca <br /> DTSC SPAPL SiEe Ater Quality site r Type Sine <br /> DzslamTRD wexa RE tl PROMm Erman' a CDAR r 9TA1Tf3 <br /> NOW@RR OF UNITS : SPA ID a, INSPECTION CODS , <br /> Nuwber of TANKS linked to Chia PROGRAM record <br /> PILLING Ate: I. the undersigned owner, operator Or aF"t of Sada. Arknowlcdge that all este and/or protect specific <br /> 3m <br /> PNS-Phourly ahArges aaaoeiated With chis facility or aetiviey will be billed co the party ids illad as the BILLING PARTY on <br /> the Maatarfile Record Infoaaacfon Form, <br /> T Alm carcify that r have pvpp"md this application and that the .ark cc be performed will be dote in aeeordaO With all SAN <br /> COGNrr Ozdinante Codas and stand"-do, state and Federal lava. <br /> APPL$CxxT,S SICMTL= , l <br /> IV <br /> Manager, Development & Operations <br /> Tsals: Environment, Health, Safety & ToxicologyDJuly 24, 1995 <br /> ADIRORMTION TO REXAMS SNPtlRmASICNe Ia addition to the above, when applleabia. X. the owner, operator or agece of Ran", at <br /> LM property located at the above #49% Addreae hereby avthoria" the releaaa of any and All results, Sectet4nical data and/or <br /> M lronaencal/site aiaHemaot ihfore,atian to SAN TOAOUII! COM= PUBLIC fth -A SCRVICDS ENYIRONNSUTAL HSALTR DIVISIGN sa soon as <br /> Lc i" available and at the same gime Le L provided to me or my reperaencntivo, <br /> DRADLI/s VA=: Inspactiat, Cvrrgnt �� / Prior I / <br /> P"" Aanune amount Paid Data of Payment Paymone Type Raceipe P Cheek t Reevd 0y <br /> CONFIDENTIAL <br /> TOTAL P.02 <br />