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0 ! <br /> SAN SCAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> M'IRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE; New " CLange Edit (PRCG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME Trf}e, <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: imnmenCal Assessment /CAP al Hazardous Waste ru est zMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site ater Duality Site ther lype Site <br /> DESIGNATED EMPLOYEE # D6 U PROGRAM ELEMENT # 2 4 7 U CURRENT STA195 <br /> ITOhIDER OF UNITS EPA M #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of aame, 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 on <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 SAN <br /> dCAQUIN COUNTY Ordinance Codes and Standards, State and Federal 1 <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZAZloca=tedi <br /> FORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the prope 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 ENVTROHI4EN1'AL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ZCPL � � I z -z / �� SO <br />