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0 • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION NASTERFIL^c RECORD FORM <br /> Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New./Change. <br /> FACILITY ID # FACILITY NAME /,p N/ //A � "✓�� <br /> PRIOR DIST # ���GG/!I"Q/��/� -- ��'✓✓✓ PRIOR SWEEPS # <br /> RECORD IO # <br /> its Mitigation: <br /> iromental Assessment T/CAP al Hazardous Waste Invest z.Mat Pipeline Invest <br /> WQCB DTSC EPA L Site ater Quality SiSe Cher Type Sice <br /> Cher Lead Agency Site en tY: ' <br /> DESIGNATED EMPLOYEE # (�g <br /> PROGRAM ELQIENT # 29.5 (.TlRRErT STATUS <br /> INSPECTION CODE <br /> NUMBER OF UNITS <br /> SPA ID #: <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> pHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY or. <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 SANT <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AOTHORIZATZON TO RELEASE INFORMATION: <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data an <br /> .iro[mmental/site assessment iaformation 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 /> / <br /> DEADLINE DATES: Inspection: Current / Prior <br /> Fee Amount Amount Paid .Date of Payment Payment Type Receipt # Qaeck # Recvd BY <br /> Zb�. Zb1• <br /> ��556 <br />