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SITE MITIGATION MPSTER£.LE RECORD FOFTM <br /> 3 � - <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised S/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID $ PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP oval Hazardous Waste Invest azMat Pipeline invest <br /> Cher Lead Agency Site geacy: WQCB DTSC EPA PL Site ate- Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE / / n g f <br /> # �y "1 PROGRAM ELEMENT # a f5 <br /> CURRENT STATUS �1 <br /> NUMBER OF UNITS : ll EPA ID #: INSPECTION CODE V <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, 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 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 /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, .then acral'cable, I, the owner, epe--ator or age.-.t 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 ENv IRONMErrAL HEALTH DIVISION as soon as <br /> it is, available and ab the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount I Amount Paid Date of Payment Payment Type I Receipt # Check # Recvd By <br /> i � <br />