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DESIGMATED ampLoYEE 4 <br />NumEER OF <br />PROORAM ELEMENT I 95-c' <br />EPA ID 4: <br />CURRENT SVC= <br />INSPECTION =CB 7 <br />Number of TANKS linked te this PRogRAM record <br />I also certify coat have prepared thia applidation and that the *ark to be performed will be done in acoordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and rederal lave, <br />APPLICANT'S SIGNATURE ! <br />Tttle, <br /> <br />Date: <br /> <br />current / DEADLINE DATES. Inspection: <br />...-vm••••••••••=. <br />Teo Amount Amount Paid Date Of Payment Payment Type Receipt * Check 0 Reevd 9y <br />0229 — O2 7? I '/p'' ago- <br />t19//2003 12:21 2094671118 <br />AGE STOCKTON PAGE 03/03 <br />SAN JOAQUIN COUNTY PUHLIC HEALTH SERvicEs <br />prvIRCIIMENTAL HEALTH D/VISTON <br />E:TE MUTTGATION NASTERFILE RECORD FORM <br />OENTRAL PROOP.AM FILE. New Change Edit (PROG4I revised 5/23/94 <br /> <br />7ACILITN ID # P C., ''/4)1T6' 5 FAG/LITT NAME <br />RECORD ID 0 ',Wept n2 / Ts-? PRIOR 0/ST 4 PRIOR SWEEPS 4 <br />I <br />pito Mitigation: <br />I <br />Environmental Aseessment <br />. <br />USC/CAF Local Hazardous Waste Invest RasMat Pipeline :nvest <br />i <br />Other Lead Agency Site <br />I <br />Agency: iflOCE DTSC <br />-- <br />EPA If.PL Site Pater Quality Site .0ther Type 3ite <br />BILLING ACKNOWLEDGEMENT; /, he undersigned owrer, operator or agent of same, acknowledge that all sitt and/or project moccific <br />PRS-DED hourly emerges a9sociared with thi, facility or activity will be billed to the pasty ideotified ae the BILLING PARTY on <br />the masterfile Record Information Term. <br />ACT4R:2ATTON TO RELEASE INFORMATICN! 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 resulta, geOtechnical data and/or <br />environmental/site aseezsment infOrmation co SAN .1DAQUIN COUNTY PESLIC HEALTH SERVICES ENWRONMEMIAL HEALTH DEVIS/oN an soon as <br />.t va available and at the same time it is provided to MA or my representative. <br />%n3jc. itti5S-