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SAN A.-L: C .- -ERVICES <br /> SITE MIT_1GATION 1.... -. FORM <br /> GENERAL PROGRAM FILE: New_ Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID $ FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmenta' Assessment ST/CAP local Hazardous Waste Invest azMac P'_peline Invest <br /> then Lead Agency Site gency: I IRWQCB DTSC EPA PL Site -ter Quality Site Other Type Site <br /> DESIGNATED EMPLOYEE # % 9 PROGRAM ELEMENT # /� CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID # / INSPECTION CODE d <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PBS-EBD 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 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 _VFORMATION: In addition to toe above, 'erhen applicable, _.e car._, opeea�tz cr agent of same, of <br /> the Property located at the above site address herebyacthcrize the release of any and all results, geotechnical data and/or <br /> anaim;:mzntaij Site assessmea[ information to SAN JOAQUIN COUNTY PUBLIC HEALTH SF.4VICE5 Enn7IPONMEDTTAr. gnagmB D+V75ION as Scor, as <br /> it is available and at the same time it is provided to me or my r=presenter-_v <br /> DEADLINE DATES: Inspection: Current / / Prior / r <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt Check # Recvd By <br /> 3i � 315- <br />