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• s <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> l�12S3 s-ate <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM, � �Q�/7 0 y <br /> GENERAL PROGRAM FILE: New Change Edit ( � (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME &4W7 ( _'�,/ <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: vironmental Assessment ST/CAP oca1 Hazardous Waste InvesC azMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQCB DISC EPA L Site -ter Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # ©//y� PROGRAMELEMENT # �t J v CURRENT; STATUS <br /> NUMBER OF UNITS : V� EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to :his PROGRAM record <br /> BILLING ACKNCWLEDGEMENT: 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 accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and F ral laws. <br /> i <br /> i <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFO ION: 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 Z Receipt # Check # Recvd V',By <br /> 23 13 o-zs. �� <br />