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SAN JOAQUiN COUNTY PUBLIC HEALTH S RV"= <br /> ^NIRONMENTAL HEALTH DIVISION. <br /> SIT MITIGATION MASTERFILE RECORD FORM <br /> y Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Cyhange f' <br /> FACILITY NAME <br /> eACILZTY ID # <br /> PRIOR DIST 9 ?RZOR SWEEPS R <br /> RECORD ID # <br /> ite Mitigation: <br /> F7mvironmental assessment ST/CAP cal Hazardous haste Invest azMat Pipeline invest <br /> ther Lead Agency Site envy: WQC3 <br /> DTSC EPA L Site ater Quality Site then Type Site <br /> 0 <br /> aq 5 <br /> jj''11111'41�!� <br /> DESIGNATED EMPLOYEE # <br /> GROGRAM ELEA�IT # CURR=YT STATUS <br /> :NSPECTION CODE <br /> NUMBER OF UNITS EPA. ID #: <br /> number of TANKS linked to this ?ROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> with this `facility or activity will be billed to the party identified as the BILLING PARTY on <br /> BILLING hourly charges associated <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and chat the work to be performed will be done in accordance with all SA-N <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, Z, 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 /> JOAQUIN COUNTY PUBLIC Hr_.AL'ri SERVICEENVIRONMENTAL VIRONMENTAL RZALTH DIVISION as soon as <br /> environmental/site assessment information to Safi <br /> it is available and at the same time it is provided to me or my representative. <br /> / Prior <br /> DEADLINE DATES: Inspection: Curren[ / <br /> nt <br /> Pa a Receipt # Check # Recvd By <br /> Fee Amount Amount Paid Dace of Payment Y� '�P <br /> 10/jo`ob <br /> [ l tS:; ISI <br />