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SAN JOAQUIN COUNTY PUBLIC FT.F,ALT•H SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MPSTERF:LE RECORD FORM <br /> GENERAL PROGRAM FILEN New-4 <br /> Edit <br /> (PROG4) revised 5/23/94 <br /> FACZL:TY ID # q I <br /> FACILITY NAME 1A TV <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest a=-'Mat Pipeline Invest <br /> Cher Lead Agency Site gency: WQCB DISC EpA L Site ater Quality Site knerTrpe Site <br /> DESIGNATED EMPLOYEE # �Z`� PROGRAM # 1 q �O CUR-RENT ST?.TUS <br /> NGM_ER OF UNITS E111?A ZD #: v� ` INSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGE'•tENT: Z, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> pHS-ETM hourly charges associated with this facility or activity will be billed to the party identified as the BI_,:NG PARTY cn <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 mit`: all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State d Federal laws. <br /> APPLICANT'S SIGNATURE : <br /> Title: BEd- e-a-ae aria Date: <br /> ALT'CRIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, :, the owner, eperatcr or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotecnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COL;NTY PUBLIC !MALTd SERVICES ENVIRON"CNTAL 'r. ACTH DIVISICV as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> z N LJ. Uct 7 �- <br /> DEADLINE DATES: Inspection: Current / / prior / / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # 02.eck # Recvd By <br /> z3�t.no 2311,0° �o f }L�� �' 603 <br />