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i <br /> SAN JOAQUIN cowry Pau= HULTH SBAYIBS <br /> ammeam IL ma= DIVISION <br /> SITS MITIGITIOy MASTBRPILS RECORD pO M <br /> GMUMAL PFA)GRAM FILE: New Qlaage Blit <br /> (PROW revised 5/23/9a <br /> FAICILITY ID � FA== WM <br /> RECORD ID # PRIOR DIST R PRIOR SWRM / <br /> Site Mitigation: 1 Assessment /CAP Local Hasardous Masts Invest �mat Pipeline Invest <br /> Lead Agency Site DTSC RPA Site er Quality Site type Site <br /> khar DESIGNATED EM:PXOYEE . S) TPROC3tAM P (s� � �TUS <br /> of CUM EPA ID N: nary-, ON 0008 <br /> Number of TAN><.S linked to this PROGRAM record <br /> BTILnIG I, the undersigned owner. operator or agent of saes. acknowledge that all site and/or project specific <br /> PHS-ZHD hourly charges associated with this facility or activity will be billed to the party identified as the Bnz= PARTY on <br /> the Masterfile Record Information Foss. <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 COURTY Ordinance Codes and Standards, State and Federal laws. <br /> JV <br /> APPL10M'S SIGNATO E w v <br /> Title: Data: <br /> AUTBORIZATION TO REIZASH IIQEMTION: 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 authorise the release of air and all results, geotechnical data and/or <br /> environmental/site assgseent information to SAN JOAQUIN CW0T2 P=ZC BERM SERVICXS ZKVIRCM4W L HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to se or my representative. <br /> DBADLINS DATES: Inspection: Current / / Prior <br /> Pee Amount Amon= Paid Data of Payment Payment Type Receipt P Check N Recvd <br /> BY <br /> �-3-r /l 9 60 61 <br />