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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New V Change Edit <br />(PROG4) revised 5/23/94 <br />FACILITY ID # <br />Site Mitigation: <br />FACILITY NAME <br />/+ / / ��' ///� �� S - <br />RECORD ID # <br />P^ t5T181 2 2-- <br />PRIOR DIST 9 <br />Recvd By <br />PRIOR SWEEPS IM <br />2'-� q °2 <br />DESIGNATED EMPLOYEE # M f PROGRAM ELEMENT # al D CURRENT STATUS <br />NUMBER OF UNITS : EPA ID #: <br />Number of TANKS linked to this PROGRAM record : <br />INSPECTION CODE : <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS -RHD 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: <br />Date <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 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 />....Z <br />DEADLINE DATES: Inspection: Current / / Prior <br />Site Mitigation: <br />VErrvironmental <br />Assessment <br />/CAP <br />Receipt # <br />cal Hazardous Waste Invest <br />Recvd By <br />�zblat Pipeline Invest <br />2'-� q °2 <br />Other Lead Agency Site <br />��L <br />Agency: <br />ou 3c)4L/ <br />�WQCB <br />DTSC <br />EPA <br />L Site <br />-ter Quality Site <br />they Type Site <br />DESIGNATED EMPLOYEE # M f PROGRAM ELEMENT # al D CURRENT STATUS <br />NUMBER OF UNITS : EPA ID #: <br />Number of TANKS linked to this PROGRAM record : <br />INSPECTION CODE : <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS -RHD 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: <br />Date <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 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 />....Z <br />DEADLINE DATES: Inspection: Current / / Prior <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />-3�'� � <br />2'-� q °2 <br />"?'/-3((Q& , ' <br />��L <br />ou 3c)4L/ <br />� <br />