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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MPSTERFILE RECORD FORM <br /> (pROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New <br /> V Change Edit <br /> FACILITY NAME <br /> FACILITY ID # �[ <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # <br /> zMat Pipeline Invest <br /> ite Mitigation: ironmental Assessment /CAP I1C_. al Hazardous Waste Invest <br /> WQCB DTSC EPA L Site ater Quality <br /> Site they Type Site <br /> they Lead Agency Site envy: <br /> Q CURRENT STATUS <br /> PROGRM ELEt�7 r # 3 O 3 <br /> A <br /> DESIGNATED EMPIAYEE <br /> INSPECTION CODE <br /> EPA ID #: <br /> NUMBER OF UNI <br /> MBTS <br /> Number of TANKS linked to this PROGRAM record <br /> operator or agent of same, acknowledge that all site and/or project specific <br /> BILLING A�OWLEDGM Mn: I, the undersigned owner, P art identified as the BILLING PARTY on <br /> pHS_EHD hourly charges associated with this facility or activity will be billed to the party <br /> the Masterfile Record Information Form. <br /> this application and that the work be performed will be done in accordance with all SAN <br /> I also certify that I have prepared <br /> and Standards, State and Federal laws. <br /> JOAQUIN COUNTY Ordinance Codes <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title- <br /> r or agent of same, of <br /> In addition to the above, when applicable, I, the owner, operato <br /> AUTHORIZATION.TO RELEASE INFORMAT <br /> e site address hereby authorize the release of any and all results, geotechnical data and/or <br /> the property located at the TY PUBLIC SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site assessor t information to � Or TCOUNY representative. <br /> SAN N <br /> it is available and at a same time it is provided <br /> Prior <br /> Inspection: Current <br /> DEADLINE DATES: ` nsP <br /> e Receipt # Check # Recvd ' BY <br /> Amount Paid .Date of Payment Payment 'rip <br /> Fee Amount <br /> o f' <br />