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• <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM o3 O 0 <br /> doopw <br /> GENERAL PROGRAM FILE: New x <br /> Change Edit / (PROG4) revised 5/23/94 <br /> bcFACILITY ID # FACILITY NAME ©�O O 5aAlx- -O 7 <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> �. <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency Site Agency: IRWQC13 DTSC EPA PL Site �ater Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # F0Q <br /> PROGRAM ELEMENT # / CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: r 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 applicati and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards,,-t'tate and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION 0 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the propert 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 a Receipt # Check # Recvd By <br />