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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> grygO[.Q.MML HEALTH DIVISION <br /> SITE MITIGATION NASIERFILE RECORD FOAM <br /> GENERAL PROGRAM FILE: New Change Edit <br /> J[ (PROG4) revised S/23/94 <br /> FACILITY IO # FACILITY NAME i OX <br /> RECORD ID <br /> PRIOR DIST # PRIOR SWEEPS # <br /> # <br /> ite Mitigation: <br /> omental Assessment /CAP 1 Hazardous waste Invest t Pipeline Invest <br /> Cher Lead Agency Site envy: WQB DISC EPA Site acer Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # U Y PROGRAM ELEMENT # 29, 0 CURRFNP STATUS �E <br /> NUMBER OF UNITS : VVV CC77 EPA ID #: VV INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING AMOWLEDGEMENI: I, the undersigned ower, operator or agent of same, acknowledge that all site and/or project specific <br /> PRS-EHD 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 also certify that I have prepared this applinstion and that the work to be performed will he 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 /> AUTHORIZATIO/at <br /> ATION: In addition to the above, when applicable, I, the owner. operator or agent of same, of <br /> the propertyve site address hereby authorize the release of any and all results, gwmechn.ical data and/or <br /> environmentanformation to SAO JOA4eIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is availae time it is provided to me or, my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �(ol. Zlol• 7. 5 •o D31 Gti` <br />