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SAN JOAOUM C=`TY PUBLIC HEALTH SERVICoS <br /> BNVIRDNMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERF= RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/2:/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ZrrvLro=ne=al Assessment /CAD Local Hazardous Waste Invest � zMat Pipeline Invest <br /> Other Lead Agency Site %gency, NQC3 1DT-gcF_ <br /> EPA Site _ter Quality Site T <br /> en Type Site <br /> DESIGNATED EMPLOYEE 9 PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF (]NITS SPA ID #: INSPECTION CODS : <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING A=OWLSDGEMMTr: I, the undersigned owner, operator or agent of Gama, acknowledge that all site and/er project s eci�ic <br /> ?HS-END hourly charges associated with this facility or activity will be biked to rhe party identified as the BILLING PARTY an <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 CDLZ1T1 Ordinance Codes and Standards, State and Federal laws. <br /> /APPLIcwr,s SIGNASURz : V10 �, VE a� <br /> Title: Y Date: L ��r <br /> AUMORMTION TD RELEASE INFORMATION: IA addition to the above, when applicable, Z, the 6wner 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/er <br /> eovirosmantal/site assessment information to SAN JOACUM COMgTY PDSI,IC HEALTH SFRVICES ENVIRO1003NTAL 9ZALTH ,OIVTSICK as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Cent / f Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check # Recvd By <br /> 90-60 <br /> .d HM:U "1VS_V:8 966 l-0E-V <br />