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PAYMF <br /> SAN JOAQUIN COUNTY PUBLIC'HEAL SERVICES <br /> ` ENVIRONMENTAL HEALTIi DIVI ION <br /> MAR 0 2 <br /> SITE MITIGATION MASTERFIU RE RD FORM i <br /> , �.. , � 7998 <br /> �r . . . . it • <br /> PUSUC HF-A <br /> c' SAN JOAuH Co j, iY h <br /> E�S ENVIRGNMENTAL H�:q�"k DfVg! <br /> KGENERAL PROGRAM FILE: New Change Edit (PROG4) revised 53/94 ` r <br /> x ' ArtLITY ID # FACILITY HAMS { <br /> RECORD ID # PRIOR DIST # PRI09 SWEEPS # <br /> t' Site Mitigation; EnvirortmentAl Assessment ST/CAP bocal Hazardous Waste Invest azMat Pipeline Invest y <br /> 70. <br /> r` <br /> then Lead-Agency; 81te envy: WQCB DTSC EPA PG Site ater Quality Site Ft <br /> Type S£te: <br /> 0 ; <br /> w y, <br /> ;'DESIGNATED EMPLOYEE f{ PROGRAM ELEMENT # S� CURRENT STATUS <br /> 4 <br />{ NUMBER OF UNITS EPA ID #: ' INSPECTION CODE i <br /> Number of TANKS iinked to this,PROGRAM record <br />�•ti::}r:. is °'.`4.?t� <br /> ga- <br /> 91, <br /> tlfi ,ING ACKNOWLEDGEMENT! I; the.undersigned owneri operator or agent of s me;'acknowledge that all site and/or project specific <br /> wfi;=EHD hourly charges associated with this facility or activity will be b�lled to the party identified as the BILLING PARTY nn <br /> the Risterfile Record information Form. I� <br /> Yi'�Fan: tr-1 <br /> aIgo certify that I have prepared this application and that thework to k4 performed will be done in accordance with all SAN yf <br /> l n <br /> �JOAQUIN COUNTY Ordinance Codec and Standards; State and Federal laws. <br /> �! <br /> 1PPLICANT'S SIGNATURE ✓ ' 'a'4S <br /> r Title: Date: Gl <br />,,4aAUTHORIZhTION TO RELEASE INFORKAATION: Irl addition to the above; when appli able; I; the owner, operator or agent of same, of l <br />+ , tie property located at the above Bite addreea hereby authorize the release of any and all results; geotechnical data and/or i� a <br />� iionmental/site aaseeement information to SAN SOkQUIN COUNTY PUBLIC HEAGm SERVICES ENVIRONMENTAL HEALTH DIVISI01j as soon as r` <br /> Il sr <br /> ,mit is available and at the same time it is provided to me or my representat -V6. if , <br /> X� 6kADLINE DATES: Inspectioni Current Prior <br /> r =.Fee Amount Amount Paid Date of PaymentAPayment Type Receipt # Check # Recvd By <br /> vlI a O V <br />