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SAN JOAQUIN COUNTY PUBLIC n UTH SERVICEES , <br /> ENVIRONMENTAL HEALTH DIVISION <br /> _. =S' ;ON [4�STERFZIm RECORD FO_ ^V <br /> GENERAL PROGRAM FILE: New l Chan EditY�eLvisj�e,d�3/2;'/�9 <br /> �4 <br /> 'ACILITY ID FACZLITY.NPMEO OIL J N&A <br /> RECORD ID # PRIOR DIST # PRIOR <br /> SWEEPSV <br /> /' <br /> 0.r Pt Qj <br /> ite Mitigation: ironmencal Assessment T/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Siteenvy: WQCE OTSC EPA L Site ater Quality Site cher Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # e ( /l D ` STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : D <br /> BILLING ACIMOWLEDGEMENT: I. the undersigned owner, operator or agent of same, acknowledge chat all site and/or project specific <br /> PRS-EHD hourly charges associated with chis facility or activity will be billed to the party identified as the BILLING PA.Y^' on <br /> the Masterfile Record Information corm. <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 /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the prooerty 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 JOAQUIN 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 /> DEADLINE GATES: Inspection: CLrrenc / / Prior <br /> Fee Amount Amount Paid Dace of Payment Payment Type Rcceina % Check # Recvd By <br /> �- <br />