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SAN SOAQUIR C PUBLIC HEALTH sERvrCCEs <br /> ENVIRONMENTA, EsALTH DIVISION <br /> SITE MITIGATION MAS'LERFILE RECORD FORT'! <br /> V/Chdnge (PROGd) revised 5/23/94 <br /> �_Edit�� <br /> GENERAL PROGRAM FILE; New_ iG.-� � <br /> FACILITY NAME <br /> FACILITY ID # <br /> PRIOR DIST it PRIOR SSiEEPS % <br /> RECORD ID !i <br /> ral Hazardous Haste Invest zMat Pipeline Invest <br /> its Mitigation: IX iroamen[al Assessment /C� <br /> QCg DISC EPA L Site Ater Quality Site <br /> [her type Site <br /> ther Lead Agency SiteCURRENT envy: <br /> PROGRAM ELEMENT # ! 4J'0 SrATUs <br /> DESIGNATED EMPLOYEE # <br /> INSpECIION CODE <br /> NU[.CSER OF UNITS : EPA ID #: <br /> Number of TANKS linked to this PROGRAM record <br /> operator or agent of same, acknowledge that all site and/or project specific <br /> BILLING ACKNON[,=^pGEMENt: L. the undersigned owner, P <br /> P}LS_EFID hourly charges associated with this facility or activity will.be billed to the parry identified as the BILLING PAR on <br /> the Mascerfile Record Information Form' <br /> red this application and that the work to be performed will be done in accordance with all SAN <br /> I also certify that I have preFa <br /> JOAQUIN COUNTY Ordinance Codes and Standards, Stace and Federal laws. <br /> � J <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> ION: In addition Co the above, when applicable, I, the owner, operator or agent Of same, of <br /> {ORIyATION,TO RELEASE authorize the release of any and all results, geotechnical data and/or <br /> the property located at above site address hereby HEALTH DIVISION as soon as <br /> environmental/site ass cement information to SAN SOAQ= COUNTY pUBLIC HEALTH SERVICSa 2Tt92RONMENTAL <br /> it is available an at the same time it is provided to me or my representative- <br /> Current <br /> epresentative. <br /> Curr�t <br /> Prior <br /> NE <br /> DEADLIDATES: Inspection: �—/��/�� <br /> Date Of Payment Payment 'type <br /> Receipt R Cheek f Recvd By <br /> Fee Amount Amojmtt 2Paiid <br />