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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New_-x�Chanye Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # � / FACILITY NAME L-9:" Me--TI-Lep- Ppe <br /> .� V <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: �[ Environmental Assessment T/CAP L40al Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency Site gency: WQCB DISC EPA PL Site Later Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # TooPROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #t ' INSPECTION CODE <br /> ':zr f7umber of TANKS linked to this PROGRAM record <br />.1;: <br /> 9ILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, Acknowledge that all site and/or project specific <br /> PHS-EHD hour] charges associated with this facilitywill be billed to the party identified as the BILLING PARTY on <br /> y r5 or activity <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 Federal laws. <br /> APPLICANT'S SIGNATURE <br /> .Title: !/LE/`��� / Date: l,6 <br /> 2�• <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />. f the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> j 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 /> tiv 7V7 <br /> orf <br /> DEADLINE DATES: Inspections Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check # Recvd By <br /> 4, <br /> 4 . <br />