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SAN JOAQUIN( COUNTY PUBLIC HEALT`i Sr'RVIC�S <br /> E NIRONy ENT;M HEALTH DIVISION <br /> - <br /> SITE MITIGATION MASTERFIL& RECORD FORM <br /> (PROG41 revised 5/23/44 <br /> ��Change Edit <br /> GENERAL PROGRAM FILE: New <br /> FACILITY NAME <br /> FACILITY ID # �OIJr� <br /> PRIOR DIST # PRIOR SWEEPS <br /> RECORD ID A <br /> ite Mitigation: vironmental .assessment ST/CAP <br /> cal Hazardous Waste Invest azMat Pipeline Invest <br /> DISC <br /> EPA L Site ater Quality Site ther Type Site <br /> they Lead Agency Site encY: <br /> PROGRAM ELEMENT # ( v CU�+tvMVr STATUS <br /> DESIGNATED EMPLOYEE # <br /> + <br /> EPA IP INSPECTION CODE <br /> '4tTMBER OF UNITS <br /> �: <br /> to this 2ROGRAM record <br /> number of TANKS linked <br /> i, the undersigned owner, operator or agent of same, acknowledge that all size and/or project specific <br /> BILLING ACKNOWLEDGEN'4ENT: <br /> Pt?S-c.S� hourly charges associated with this `acility or activity will be billed to the party ident__ied as the BILLING PAR or' <br /> the Masterfile Record Znformat_on 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 /> SOAQUIN COUNTY Ordinance Codes and Standards. State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> / Date: <br /> Title: 7 <br /> ION: In addition to the above, when applicable,. I, the owner, operator or agent of same, of <br /> AUTHORL2ATION TO RELEASE INFORMAT <br /> authorize the release of any and all results, geotechnical r d/or <br /> site address hereby soon as <br /> the property located at the above COUNTY PUBLIC Hr—ALTH SERVICS ENVIRONMEN'= [C }r <br /> environmental/site assessment information to SAN 30AQUIN representative. RE v G <br /> it is available and at the same time it is provided to me or my P <br /> flE� <br /> 31 <br /> w cou�n <br /> eV4\jj LotApAR�M� <br /> Currant <br /> r Prior / / ��H 0 <br /> / <br /> DEADLINE DATES: .Inspection: f <br /> Da <br /> of Payment Payment Type Receipt # Check A Recvd BY <br /> Fee Amount Amount Paid <br /> 1, <br />