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R • <br /> PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEI\/ED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM OCT 2 1 2003 <br /> PUBLIGONEOPLIH S RV CE 04 <br /> ENVIROtJMFNTPR 1�I4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change Edit ( <br /> FACILITY ID # ^ . Oo ,5 Z O 71 FACILITY NAME J 10 '��S C•(�6 !fit V Q C'(d� (P'I�C(� <br /> RECORD ID # 1 S a"�0 IS— PRIOR DISE # PRIOR SWEEPS # <br /> P/� TA (11 <br /> Site Mitigation: vironmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site -ter Quality Site I 10ther Type Site <br /> q/ <br /> DESIGNATED EMPLOYEE # A — PROGRAM ELEMENT # / CI`� CURRENT SLATOS <br /> ME <br /> NUER OF UNITS ` TEPA ID #: (/ INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-RHD 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 FOM. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> TA)t) llado� <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ✓S �7 rf20 <br />