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SAN SOAQUIN COUNTY PUBLIC HEALTH SERVICES I� <br /> ENVIRONMENTAL 1D:A7'TH DIVISION <br /> SITE MITIGATZ6N MASTERFILE RECORD FORM / <br /> (pROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: <br /> New Change Edit <br /> 14014 <br /> /_� 1/ FACILITY NAME <br /> FACILITY ID # V� �(" <br /> Q PRIOR DIST # PRZOR SWEEPS # <br /> RECORD ID # Sa �V S� <br /> cal Hazardous Waste Imrest <br /> azMat Pipeline Invest <br /> its Mitigation: nvironmental Assessment ST/CAP <br /> envy: WQ® <br /> DISC EPA L Site ater Quality Site ther Type Site <br /> Cher Lead Agency Site <br /> p PROGRAM ELEMENT # �y1 CURRENT STATUS <br /> DESIGRAATED EMPLOYEE # O . <br /> INSPECTION CODE <br /> NUMBER OF UNITS <br /> EPA ID #: <br /> Number of TANKS linked to this PROGRAM record :�---- <br /> ttsc all site and/or project specific <br /> OWLEDGEMENT: the BILLING PARTY on <br /> I, the undersigned owner, operator or agent of same. acknowledge ted with this facility or activity will be billed to the party identified as <br /> PILLING hourly charges associa <br /> BILLING AC1@I <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 /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE 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 JOAQUM 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 /> Prior <br /> DEADLINE DATES: Inspection: CurrentZi <br /> Fee Amount Amount Paid ment Payment Type Receipt # <br /> Check # Recvd By <br /> S/ <br /> P4 <br /> - -711, (p ✓ says <br /> i � <br />