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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 2NVZRQ'V'MTM HEAL7A DIVISION <br /> SITE MITIGATION . <br /> `>1,�I;.c^, RECORD FORM <br /> GENERAL PROGRAM FILE: r <br /> New Charge-Cd; <br /> FACILITY ID # I ^^--�� (PROG4) revised S/23/94 <br /> 11� FACILITY NAME //� rl/ <br /> RECORD ID # 1 /N` / <br /> PRIOR DIST # <br /> PRIOR SWEEPS # <br /> ite Mitigation: <br /> ^iv.ronmental Assessment /CAP call Hazardous Waste invest <br /> ther Lead Agency Site azMat Pipeline Invest <br /> gency: WQCB DISC EPA PL Sire ater <br /> Quality site the_ <br /> ' 'i}�pe Site <br /> DESIGNATED EMPLOYEE <br /> PROGRAM ELrh1ENT # <br /> C✓'-'+Z . STATUS <br /> NUMBER OF UNITS <br /> �� EPA ZD #: <br /> INSPEC^ION CODE <br /> 'lumber of TANKS linked to this PROGRAM record ; <br /> BILLING ACIQNOWL^ <br /> "'`��NT: I, the undersignedPHS-EHowner, operator or agent of same, acknowledge <br /> this facility g that all site and/or project s eci_i <br /> the Masterfile Record information Y or activity will be billed to the part identified <br /> c <br /> Form_ y identi_�ed as the 3ILLING PARTY on <br /> I also certify that I have prepared this application <br /> JOAQUIN COUNTY Ordinance Codes and Standards, and that the work to be <br /> SAN will be done in accordance with all SA <br /> State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, <br /> the property located at the above site address hereby authorize Lice release of an <br /> information to SAN JpAQUZv Y and all results', geotechnical data and/or <br /> it is available and at the same time it is LINTY PUBLIC qEALTH my representative.SERVICES <br /> provided to me or ZRONMLENIAL HEALTH OZVISZON as soon as <br /> DEADLI.'VE DATES: I �v-O <br /> inspection: Current _ <br /> Prior _/ <br /> Fee Amount Amount Paid Date of ? / <br /> avme_zt <br /> Payment Tv <br /> pe Receipt <br /> Check # Recvd By <br /> Alp <br />