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y" . <br /> COY.-FUBf.IC <br /> Pik <br /> TA'SERVICFS s. <br /> 3OiAp[TIIQ <br /> h ENNIRCv4mn%L HEAT TS ION r r = } <br /> r�. SITS KMGATICK i ASTERF LE FORM <br /> qY" ��3`n3k'�.. _'� „�,,.r � », -� �W3'. x;�,�.� -y ti• ''f��" <br /> ##. V <br /> V"' r �' i i:, s f •,ss ,(' t v 3" <br /> GSNERAL�PROC,RAT! FILE: °" Nei : Edit �5:. r l`` <br /> Id /94 <br /> e < +'; y SPROC,4) revised 5/23 s � . <br /> MO7fs�k' '. ''.�-,b K <br /> IF ice <br /> yRFy ~# \ ;,• 3 r" !' �? 14EtR1 a` p <br /> ,RECORD # a° � � r FRIDR DIST # o r + ,� *� h PRISWBSPB # sn z <br /> �, .y k. r � ...i.. tN � _. .,i.�s2£`p 'r.� �. ,y a� - �'. 'Y N�-•t'' a as,4e��y ti r, �,p�,. <br /> . 74iti t1aII syj Y Ass ^t ?� Ham rima Naste,Invest r t Bipeline Invest <br /> t, .s � �. �#•4 1�.1:�.s -1S-Y..Y F:l ...�Sf�'+M'ri!'! }'^'k. 4-a :1A�V9�'R�i�r%^m'd. <br /> AY,zl pt tea+ m <br /> Agency Site a DTSC SFJi' Site -ater�Quality Sa tG * Site <br /> earl .f_ a C• <br /> N,ir r.F# •!d"r drr.; '� r�€iC la ''k�. ,� kx r'' '.�'k R'' _ <br /> 'a" ass i''�k iit L3 - k�..r[s t1' 3 •} + #:. i,T� }}kftr r = rt v? <br /> ed.5 ei T. <br /> -x �ttr�i '1'�r` <br /> Xi DESIGli►TED new= # _� V S{�Y�\Jt PROGRAM �►T� <br /> 3( <br /> SFR OF,QMi `SPA`�D # INS`PEGTIOH CODE 4 i1 r <br /> +! r ,. .• }i-.; *rs ani"l y x� �7�,<-, <br /> NtmEber <br /> 6f,TANKS linked to this-PROGRAM record <br /> 'BILL= I.• the't�mderaigned woes, operator or,ap= f same. aelmowl a that a77'Bite orpzn3ect specific <br /> . t4 PHS-E8D hourly charges associated with this,facility or activity will billed to a party identified as`the HTTT-T*T(="PARTY on <br /> F -,} <br /> Masterfile Record Information Form.- <br /> I alsD certify that-1 have prepared this`application t°the t ' a will be don accordance with all SAN <br /> JOAQOIN COONw ordinance Codes and Standards State and F <br /> y M <br /> ^ �.+r I�r,,, _''r •,r-ti."3'S- "r �' .r kh+li�sz ' <br /> Ai:J.ae z� k - f "t r >'.��,•rt�h t <br /> .APPLICAWr'S SIGNATURE <br /> Date <br /> !} <br /> � ,Sit ; ,?' r• t _ kynt a• `-^rs <br /> 14 <br /> ADTEORIZATION TD RELEASE (�__�,yy• in addition to the above: when pplicabie I :tha owner, operator or,:ageat of same, of <br /> r `.t' <br /> t�th property located at above site address hereby authorize the r ease of any_and�all resulta, geotechnical data`and{or <br /> enviscnaiem /site ase anent"inform ation to SAN JOAQp'A4T COUNTY PUBLIC HEALTH SERVICES EDNIRONMBNTAL HEALTH DIVISICX as soon as <br /> saf'available and at the'same time�It is provided to me or my�repres ti <br /> ve. v t , <br /> 1� k,�z'�•:.�''F .xt'e r+�.idh�rr. r~ - '� 1�'" � � t :: �'" w ..J.u"`�s - <br /> r r -v 9 c...-_ �T'� T� �tr ,� c:;§ffi t ..g� �f��4 t s. ����•,Yt _ ' <br /> le RN <br /> DBADLIM DATES: In ", current " Prior <br /> 3a� A" + <br /> R Fee Amount a *�Pa d. Date of Payment <br /> 'Payment Type Receipt # Olxetk# t Reevd BY <br /> e4.9- :1 °l <br /> .. <br /> .3 T.rf <br /> IM <br />