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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASIFRFILE RECORD FORM <br /> Edit ,/�/.//�T� •iVV (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Qtange '�G�v '1 <br /> FACILITY NAME <br /> FACILITYID # <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD IO # <br /> ironmental Assessment <br /> al Hazardous Waste Invest zMat Pipeline Invest <br /> ice MiCigacipn: <br /> ther Lead Agency <br /> Site ency: NQCB OTSC EPA L Site ater Quality Site ther Type SiCe <br /> PACGRAM ELEt4'NI # C71110 rI S'IATGS <br /> DESIGNATED EMPLOYEE # O� <br /> HiSpECIION CODE <br /> NUMBER OF UNITS <br /> EPA ID #: <br /> Number of TANKS linked to this PROGRAM record <br /> oeraCor or agent of same, acknowledge that all site and/or project specific <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, a <br /> pgS_� 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 Chis application and that the work to be performed will be done in accordance with all SAN <br /> and Federal laws. <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State � <br /> APPLICANT'S SIGNATURE <br /> Dace: <br /> Title: <br /> rator <br /> of <br /> AVCHORIZATION TO RELEASE INFORMATION <br /> ,i In addition to the <br /> th�'e theerelease oflanyland all�resultse geoteoclmicaltdatasand/orE <br /> the property located at the abav site address hereby HEALTH DIVISION as soon as <br /> ozmation to SAN JOAOOIN COUNTY PUBLIC HEALTH SERVICES ENVIROIPENTAL <br /> envirpnmental/site assessmen to me or my representative. <br /> it is available and at th same time it is provided <br /> / / Prior <br /> DEADLINE DA Inspection: Current <br /> Fee Amount Amount Paid .Dace of Payment <br /> Payment Type Receipt R Check # Recvd BY <br />