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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MNSTERFILE RECORD FORM <br /> 11 <br /> GENERAL PROGRAM FILE: New Change <br /> Edit G/11�i'1TE (PROG4) revised 5/23/94 <br /> FACILITY ID % <br /> 1= DDI T— FACILITY NAME <br /> 1 PRIOR DIST p PRIOR SWEEPS % <br /> RECORD ID k PR n 5a I ? <br /> /� al Hazardous Haste Invest zmat Pipeline Invest <br /> I <br /> itigation: ironmeneal AssessmanCLead Agency Site ency: WQCB DISC EPA L Site ater Quality Site [her Type Site <br /> /n PROGRAM EI.II'4T`"I % 29 CO&RENT STATUS <br /> DESIGNATED EMPLOYEE H 01lL (� <br /> INSPECTION CODE <br /> NUMBER OF UNITS : EPA ID q: <br /> Number of TANKS linked Co this PROGRAM record / V <br /> BILLING ACICNOWLEDGEMENL: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> PHSLING hourly charges associated <br /> the Masterfile Record Information Form. <br /> d that the work to be performed will be done in accordance with all SAN <br /> I also certify that I have prepared this application an <br /> JOAQUIN COUNTY Ordinance Codes and Standards. State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> ION In addition to the above, when applicable, I. the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEASE INFORMAT <br /> authorize the release of any and all results, geotechnical data and/or <br /> the property located at the abw site address hereby <br /> environmental/site assessment ormation to SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at th same time it is provided to me or my representative. <br /> / / Prior <br /> DEADLINE DA S: Inspection: Current <br /> Amount Paid <br /> Fee Amount .Date of Payment <br /> Payment Type Receipt R Check Y Recvd By <br /> r � <br />