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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> II4VIROiI. HEAD DIVISION <br /> SITE MITIGATION 14ASi'ERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: NewChauge Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY lull's b <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> site Mitigation: nmental Assessment ./CAP Loocal Hazardous usaz rungs Waste Invest t Pipeline Invest <br /> then Lead Agency Site QCB DISC EPA Site F-t <br /> Quality Site her Type Site <br /> -F <br /> DESISTED EMPLOYEE # U//� PROC�tAM ELe?�Ff # 2qJ� CURRENT s <br /> NUMBER OF UNITS C��Svv EPA ID #: INSPECTION CODE : <br /> Number of TANKS Linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sa�ledge that all site and/or project specific <br /> PFS-EHD hourly charges associated with this facility or ac-rivi be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this appli ion and that the work to be performed will be dame in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and S State and Federal laws. / <br /> APPLICANT'S SIMULTURE : <br /> Title: Date: <br /> AUTHORIZATION TO INFCFJ9 ION: In addition to the above. when applicable. I, the owner, operator or agent of same, of <br /> the property 1 ted at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> eavizoxanen ite <br /> as <br /> information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIR@�L HEALTH DIVISION as soon as <br /> it is a / le and at the same time it is provided to me or my representative_ <br /> DEADLINE DATES: Inspection: C==ent / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Receipt # C.e # Recvdy <br /> �lqlf2� Z <br />