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'r+ --Poo 'LSC L+^r /`t"" e 4, 1 lam <br /> ( �/ <br /> �`���AN JOA¢UIN Cat1NTY <br /> PUBLIC HEALTH <br /> SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MXSTMF'LS SRECORD FORM <br /> (PROG4) revised 5/23/94 y <br /> GENERAL PROGRAM FILE: New Change <br /> Edit <br /> FACILITY ID # FACILITY NAME ""�' - - 5_0 71,65 <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # <br /> its Mitigationironmental Assessment /CAP <br /> al Hazardous Waste invest zMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSC SPA L Site ater Qty Site <br /> ualither Type Site <br /> DESIGNATED &MPLOYEE # <br /> PROGRAM ELEMENT # '..?r QR�1 STATUS <br /> NUMBER OF UNITS <br /> EPA ID #: INSPECTION CODE <br /> Number of TAM linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: T, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> M_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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> AUTHORIZATION 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 J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> qq <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />