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SAN JOAQUIN COUNTY PLIC REALM SERVICSS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM ?ILE: New Chaa<]e Edit (PROG4) revised 5/23/94 <br /> FACT= ID % FACILITY NAME <br /> RECORD ID % PRIOR DIST k PRIOR k <br /> ita Mitigation: omental Assessment /CAP 1 Hnrazdous Waste Lnvesc t Pipeline lnvesc <br /> Cher Lead agency Site envy: c3 DTSC EPA I Site -ter Quality Site Cbc Type Site <br /> DESIGNATED EMPLOYEE % �/^ PROGRAM EL44NT % 12?-561 CURRENT STATUS <br /> NUMBER OF UNITS V/ CCCUJJJr�z F7EPA ID k: DSPEC^ON CODE <br /> Number of TANKS Linked to this PROGRAM record <br /> 3ILLING ACXNONLZnGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-MM hourly charges associated with this facility or act--v Cy will be billed to the party identified as the SELLING PARTY an <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and c the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, SG and Federal laws_ <br /> APPLICANT'S SIGNATURE 4Lte� <br /> Title: Date: <br /> AUTHORIZATION TO RETE WORMATICN: In addition to the above, when applicable, I. the ower, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geateefnical data and/or <br /> ecvi_-onmental/site assessment information to SAN JOAQUIN COUNTY PUELIC HEALTH SERVICES ENVIRONMENTAL REALTN DTVLSION as scop as <br /> it is available and at the soma time it is pravided to me ar my representative_ <br /> DEADLINE DATES: Inspection: Cuzxmt / / P=ar <br /> epee Amount Amount Paid Date of Payment Payment Typej Receipt k Check % Recvd By <br /> Z3s��U -"— ° 15 31 �23.°� <br />