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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES pP.`1vG`r`'`NI D <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTEPFILE RECORD FORM C`c n 9 2003 <br /> J�`JOPC7�N S O�SS10N <br /> SPN GHt NE P1T1101� <br /> GENERAL PROGRAM FILE: New Change Edit (P� c p{ i5 ed 5/23/94 <br /> q <br /> FACILITY ID R � D D l l I�- FACILITY NAME 11 . O`�( /1 be <br /> RECORD ID p 5 �1! �3 3 PRIOR DIST 0 PRIIOR SWEEPS >% �T <br /> site Mitigation: ironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site envy: 1EWQCB <br /> DISC EPA L Site ater Quality Site cher Type Site <br /> DESIGNATID EMPLOYEE PROGRAM ELEMENT R CURRENT STATUS <br /> NUMBER OF UNITS ll EPA ID p: INSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING AC,NC,,ZUGEMRU: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project spec=k <br /> PHS-ERD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY or. <br /> the Masterfile Record Information Form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SA.v <br /> dOAQUIN COUNTY Ordinance CodesandStandards, State and Federal laws. <br /> APPLICANT'S SIGNATURE .0- <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN SOAQUIN COUNTY PUBLIC REALM SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same 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 Y Check % Recvd By <br /> 7 q 76 <br />