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fl{ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> !i \\ ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MAST£RFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New nge Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILI'T'Y NAME <br /> RECORD ID # 54�? {/1? I R DIST # PRIOR SWEEPS # <br /> ire mit3gAtion�rr_� �nvironmental Assessment ST/CAP Local Hazardous Haste Invest z1Nat Pipeline Invest <br /> Cher Lead Agency Site Igency, L <br /> �147 <br /> DTSC EPA L Site -ter Quality Site101--her Type Site <br /> NO-O-L Inv r <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # •*J ` CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: C.-- `1 INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> 3ILLING 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 accordande with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> tEvNE <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operato c of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geot�V. t� or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL �IYS 4as soon as <br /> it is available and at the same time it is provided to me or my representative. U1N cou SES <br /> Spti}0��NpA`�HEq�a1V15ti�� <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> a(p� J7. L�L"7 � <br />