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PAYMENT <br /> SAN JOAQUIN COUNTY PL3LIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION �oOC <br /> SITE MITIGATION MASTERFILE RECORD FORM AUG 2 U <br /> SAN JOAQUIN COUNTY <br /> ENTDEPA NT E HEALTH DEPARTMENT <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # O O` Q q FACILITY :TAME <br /> RECORD ID # �OO( l ` O PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: xEnvironmental Assessment 1UST/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: WQCBDTSC EPA L Site ater Quality Site I 10ther Type Site <br /> /310 <br /> � 3�S <br /> DESIGNATED EMPLOYEE # D� PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 cc 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 /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> �J <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO PELEASE INFORMATION: 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 authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �zg5, Lg'S. �2 3• � oi5 3�� Gx� <br />