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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILEN New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # r*O O 6! S-q (f FACILITY NAME �' p�/yt �YP 0_0 <br /> RECORD ID PRIOR DIST # PRIOR SWE=25 # <br /> J `{ -�"2 /4t-\rort lnlrn.r !y(c, i-t,><tcs <br /> ite Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline invest <br /> that Lead Agency Site envy: WQCB DTSC EPA L Site -ter Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # L '� ( PROGRAM ELEMENT #. `L S CURRENT STATUS <br /> NUMBER OF UNITS : RJ EPA ID 4: INSPECTION CODE <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 Sone in accordance wich 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, 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check # Recvd By <br />