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• P,XyMI ENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRON HEALTH DIVISION <br /> SITE MITIGATION KASTERFILE RECORD FORM (�p R 3 O 2004 <br /> SAN JOAQUIN 0"-'Ty <br /> / ENVAFt�'�` <br /> HCh�q) �evChange n P)A <br /> ise 5/23/94 <br /> GENERAL PROGRAM FILE: New Fdit <br /> FACILITY NAME <br /> FACILITY ID # <br /> PRIOR DIST # PRIOR S'eIEEPS # <br /> RECORD ID # D <br /> Ether <br /> ation: vironmental Assessment T/CAP <br /> al Hazardous Wase Invest zHat Pipeline Invest <br /> Agency Site envy: <br /> WQp DISC Epp L Site a[er Quality Site then Type Site <br /> �j� TLL==URLP=-r2qTATUS <br /> FDESIGNATED EMPLOYEE # PROGRAM ELEMEa # LINSPECTION CODE <br /> OF UNITS : _� <br /> EPA ID #: <br /> lumber of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge [hat all site and/or project specific <br /> pHS_EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> ation and that the work to be performed will be done in accordance with all SAN <br /> I also certify that I have prepared this applic <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> _�y <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> RMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEAS Y11 geotechnical data and/or <br /> the property located t the above site address hereby authorize the PUBLIC <br /> easeHEALTf SERVICES <br /> acENVIRONMElTALHEALTH DIVISION as soon as <br /> environmental/site assessment information to SAN JOAQUIN COUNTY representative. <br /> it is available and at the same time it is provided to me or my re p <br /> / Prior /M%*B <br /> Ym a Recei [ # Checke of Payment Pa ent Typ P �2�a- ?� <br /> C- <br /> 4- <br /> e( <br /> a v I.qjx--47 !� <br />