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Mrd %woof <br /> SAN SOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New C] Change Edit (PROG4} revised 5/23/9; <br /> If <br /> FACILITY ID 4 /Q0�e- DSS FACILITY NAME <br /> RECORD ID ( }� PRIOR DIST # PRIOR SWEEPS k <br /> ite Mitigation: X Environmental Assessment ST/CAP cal Hazardous Waste Ines[ kzMat Pipeline invest <br /> ther Lead Agency SiteAgency.' WQCS OTSC I EPA PL Site a[er Quality Site I 10cher Type Site <br /> DESIGNATED --,PLOYEE I.�Ll 7 PROGRAM ELc'M.C.'NT .'� �.L�. f] F;;�ENT <br /> STATUS <br /> NUMBER OF L'NiTS LL EPA ID 4: V ( y INSPECTION CODE re <br /> "Furber of ?'ANM linked to this PROGRAM record : <br /> BILLING AC?UZOWLEDG-EMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be pilled to the party identified as the BILLING ?ARTY on <br /> the Masterfile Record Information Form. <br /> I also cert_fy that I have prepared this application and that the :cork to be performed will be done in accordance with all SAN <br /> JOAQUIN COL-,N7Y Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> i <br /> - <br /> Title: Date <br /> AUTHORIZATI,GN 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 TOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL REACTS 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 4 Check Recvd By <br /> o�boD �70� I a� �� 3 7 '3 1 <br />