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(YU1� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> Edit (PROG4) revised S/23/94 <br /> ,,-,-IERAL PROGRAM FILE: Ne a s <br /> 1 <br /> S FACILITY NAME £ <br /> FACILITY ZD # �,- %_ <br /> _* PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # , . <br /> al hazardous Waste Invest <br /> azMat Pipeline Invest <br /> ite Mitigation: ironmental Assessment T/CAP <br /> ther Lead Agency Site envy: <br /> WQCB DTSC EPA L Site ater Quality Site then Type Site <br /> i <br /> ) <br /> a <br /> i <br /> a <br /> PROGRAM ELEMENT # a,�5 ( CURRENT STATUS DESI <br /> GNATED <br /> EMPLOYEE # �� <br /> INSPECTION CODE <br /> OF UNITS EPA iD #: <br /> Number of TANKS linked to this PROGRAM record <br /> operator or agent of same, acknowledge that all site and/or project specific <br /> 1 I, the undersigned owner, p <br /> BILLING ACXNOWLEDG ANT: rt identified as the BILLING PARTY on <br /> psSS_� hourly charges associated with this facility or activity will be billed to the party <br /> the Masterfile Record Information Form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> OAQUIN COUNTY Ordinance Codes and Standards. State and Federal laws. <br /> • i <br /> APPLICANT'S SIGNATURE <br /> uC 0 -1996 <br /> `n A <br /> Date: <br /> Y V` r'Jp <br /> Title: <br /> applicable, I, the owner, operator or aC o�same, of f <br /> INFORMATION: In addition to the above, when aPP i <br /> AUTHORIZATION TO RELEASEand all results, geotechnical data and�/ar <br /> site address hereby authorize the release of au}r i <br /> the property located at the above PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PU rIC REALTH S I <br /> it is available and at the same time it is provided to me or my p f <br /> / / Prior <br /> DEADLINE DATES: <br /> Inspection: Current <br /> ceipt # <br /> Amount Paid Date of Payment Payment Type ReCheck # Recvd By <br /> Fee Amount ot <br /> 39 <br />