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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION /y�1 -n <br /> SITE MITIGATION MASTERFILE RECORD FORM /Wit- <br /> ()'%fin i 19F-630- 0,1 <br /> 9F-6'f0— 0,1 <br /> GENERAL PROGRAM FILE: NewXChange Edit (PROG4) revised 5/23/94 <br /> T/ FACILITY NAME <br /> FACILITY ID # U ( ?�(5 V�v—v�X1 J f <br /> RECORD ID # P e. 515 5 25 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site envy: I WQCB I I DTSC I I EPA I L Site -ter Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # I ©h/� PROGRAM ELEMENT # 2t SV CURRENT STATUS <br /> NUMBER OF UNITS : V� EPA ID #: 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 done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and F ral laws. <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 /> 0 Of�551 S <br /> DEADLINE DATES: Inspection: Current / / <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Payment Receipt # Check # Recvd By <br /> 23 23 0-yZ /d <br />