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SAN JOAQUIN CODNTY pUBLIC BEALT9 SERVICES <br /> ' EE MONMENt3 L BMTR DIVISION <br /> SITE MITIGATION b1ASTERFILE RECORD `ORM <br /> Q[ Edit <br /> (pROG4) revised 5/23/94 <br /> GENERAL pROGRAM FILE: Nev /" Change � <br /> FACILITY ID # pACILITY NAME <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # <br /> G <br /> its Mitigation: irornnental Assessment /CAP <br /> al Hazardous oasts Invest shat Pipeline Invest <br /> Baty: QCB DISC EPA <br /> L Site ater Quality Site ther Type Site <br /> Cher Lead Agency Site <br /> # CMME Tr STAINS <br /> DESIGNATED EMPLOYEE # PROGRAM ELELNr "�•✓� <br /> mpyLTiON CODE <br /> NUMBER OF UNITS <br /> EPA ID #: <br /> Number of TANKS linked to this PROGRAM record <br /> acknowledge that all site and/or Project specific <br /> BILLING ACKNOWLEDGEMENT, I, the undersigned owner• operator or agent of same, <br /> PHS <br /> _EM hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I icatien and that the <br /> work to b ormed will be done in accordance with all SAN <br /> also certify that I have Prepared this aPPl <br /> and Standards, State and Federa <br /> 30AQUIN COUNTY Ordinance Codes <br /> ApPLICANT'S SIGNATURE c <br /> Title: <br /> when a licable, I, the owner, operator or agent of same, of <br /> g 1ORMATION: In addition to the above. pP cal data and/or <br /> AUTFIOAIZATION,TO authorise the release of any and all results, geotechnical <br /> loco at the above site address hereby gI'•ALTH DIVISION as soon as <br /> the property COUNTY PUBLIC HEALTH SERVICES M171RON42SM <br /> environmental/ to assessment information to q}ugA4 or my representative. <br /> it is avail le and at the name time it is provided <br /> Prior._/�/ <br /> DFApl,WE DATES: Inspection_ Current BY <br /> . pate of.Payment payment �Pe <br /> Receipt # Check <br /> See AmounC Amount paid <br /> Zoo z��• 3 <br />