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SAN "'QUIN COMrl'Y PUBLIC HEALTH SERVICES <br /> ENVIROOMML HEALTH DIVISION - - <br /> SITE MITIGATION MASTEEFILE RECORD FORM �I <br /> �2 Lt e -lid <br /> GENERAL PROGRAM FILE: New <br /> Change Edit <br /> ' (PAOGq) revised 5/23/94 <br /> FACILITY ID # 0/,� �.(�6 _ <br /> FACILITY NAME <br /> RECORD ID PRIOR DIST # <br /> ' PRIOR SWEEPS # <br /> its Mitigation: 'ronmental Assessment <br /> /� cal Hazardous Waste 7mrost <br /> zMat Pipeline InvesC <br /> ther Lead Agency Site envy: WQCH <br /> DISC EPA I Site ater Quality Site Cher <br /> Type Site <br /> DESIGNATED EMPLOYEE !t. <br /> /��(f � # a � � �A�s <br /> NUMBER OF UNITS EPA ID #: <br /> INSPECTION CODE <br /> Number of TANKS linkedhis PROGRAM record . <br /> BILLING ACMMLEDG61ENT: I, the undersigned Owner,. operator or agent of same, acknowledge that all site and/or <br /> PHS-EHD hourly charges associated.with this facility or activity will be billed to the project specific <br /> the Masterfile Record Information Form. Party identified as the BILLING PARTY on <br /> I also certify that I have Prepared this application and that the work to be Performed will be done in accordance with all SAM <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Date: <br /> ADTHOEIZATION 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, <br /> environmental/site assessment information t0 SAN gmtechnical data and/or,IO <br /> AOUIN COMITY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is Provided to ms or <br /> my representative. <br /> DEADLINE DATES: Inspection: Current - <br /> / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Reevd By <br />