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k �• _may„ � .i /�p <br /> 4 �f <br /> i <br /> 3 <br /> SAN JCAc= CatLcTy PUBLIC Hli.1LTH SERv1=S I <br /> h`WIRONMENTAL f rEALTH DIJISION� ! <br /> SITE MITIGATION MAZ=RF= RECCRD FCRM <br /> ,I <br /> I <br /> �' i <br /> GENERAL PROGRAM FILE: New J`- ` Change Edit i (PROGO revised "a/23/94 <br /> II <br /> i <br /> FACILITY ID FACILITY NAME <br /> RECORD ID # Q �D r b PRIOR DIST # PRTOR S!IESPS Ise <br /> ;I <br /> I <br /> ireamental Asaesement /CAP .oval Hazardous Waste Invest zMat Pipeline Invest d <br /> 3i-.e M� igation: i <br /> i <br /> other Lead Agency Site enoyl W4C6 DISC EPA L SiCeij seer Quality Site Gher Type Site <br /> i <br /> i <br /> S <br /> DESIGNATED r�ZFF.oY££ # PROGRAM ELEMENT # ` 5 C(7RRFSIC STAT(TS <br /> LLL q <br /> IiU�M£R OF [RfI'"'S SPA ID N: ! INSPECTION CODS <br /> Number of TrIKKa l;eked to this PROGRAM rec=d <br /> i <br /> BILLING ACKNOWLMGEMENT: I, the undersigned owner. operator or agent of same, acknowledge that all Site anal/or project Tpec:fic <br /> i <br /> PHS-EHD hourly charges associated with this far lity zr activity will be billed to t.he party ideneified as the BY ,LZNC PARTY on <br /> the nase.erfile Record Information Form. <br /> i <br /> I also certify that I (lave prepared this applicat;o^ and that the work to he per`ormAd will bP done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> PAYMENT" <br /> APPLICANT'S SIGNA1M ! -R 3 yy;�y '`y� <br /> i ly V <br /> i <br /> MN JOAULm\i ,L, <br /> V/PIlO., PUBLIC HEALTH SERVICES <br /> Title: Dat•' - �1 <br /> ! NnVENTAL HEALTH L?f4rISIC : <br /> I <br /> i <br /> AUTHORIZATION TO RELEASE INFCRMATICN: In addition to the above, -hen applicable, Z, the owner; operator or agent of same, of <br /> the property located at the above Bite address hersby authorize the release of anyaid all. results, geotechnical data andior <br /> i <br /> errrirorrnental/site assasiment information to SAN JOAGUM CJIINTY PCaLIC NEALITH. SEMzrICES =VIRCNM.ENTAL HFALTH OrJT5I01; as soon ns <br /> i <br /> it is available and at the same time it is provided to me or my representative- <br /> 4. !.1�L.�:( i <br /> - i <br /> i <br /> DEADLINE DATES: Inspection: r-%="t I f Prior <br /> ! <br /> Fee Amount amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 9 <br /> ��b i -'�JD�� 0� 103 <br />