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R <br /> SAN TOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New C�ange <br /> Edit (PROG4) revised 5/23/94 <br /> 3 FACILITY NAME <br /> FACILITY ID # <br /> ^ PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # TF d� <br /> vironmental Assessment /CAP <br /> aI Hazardous Waste Invest zMat Pipeline Invest <br /> rte Mit igacicn: <br /> ..PA cher a Sic^ <br /> ther Lead Agency Site envy: <br /> HQ® DISC L Site aces Quality Site TYP - <br /> tDESIGNIATLOYEE # O INSPECTION CODE <br /> EPA ID #: <br /> linked to this PROGRAM record <br /> BILLING hourly charges <br /> I, he undersigned owner, operator or agent of same, acknowledge that all site and/or Project specific <br /> AMOW <br /> PNS-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 /> pared this application and than he work to be performed will be done in accordance with all SAN <br /> I also certify that I have pre <br /> State and Federal laws. <br /> JOAQUIN COUNTY Ordinance Codes and Standards' <br /> APPLICANT'S SIGNATURE c <br /> Date: <br /> Title: <br /> Alfl'HORI ZATION TO RELEASE INFORMATION: In addition Co 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 UOAQUIN EN <br /> COUNTY PUBLIC HEALTH SERVICES VIRONqNTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> / / Prior <br /> DEADLINE DATES: Inspection: C1 ent <br /> Aunt Paid .Dace of Payment Payment Type Receipt # Check # Recvd By <br /> Fee Amount mo <br />