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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: <br />(PROG4) revised 5/23/94 <br />FACILITY ID # <br />_ P,0 o /1 O ^1 <br />d Vb L <br />FACILITY NAME <br />��. ,'i'�' Fa RL2 <br />mT[� �vic0 <br />RECORD ID # <br />O S 1 \T 3• <br />PRIOR DIST # <br />local <br />PRIOR SWEEPS # <br />1 <br />1303 Fir? -%T -ST'- ESC�icovL <br />DESIGNATED EMPLOYEE k b , PROGRAM ELEMENT # Z Ct 5�0 CURRENT STATUS <br />NUMBER OF UNITS : 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 Federal laws. <br />APPLICANT'S SIGNATURE <br />AUTHORIZATION TO RELEASE INFORMATION: 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 <br />Site Mitigation: <br />Ab4nvironmental <br />Date of Payment <br />Assessment <br />ST/CAP <br />Check # <br />local <br />Hazardous Waste Invest <br />1 <br />azMat <br />14 <br />Pipeline Invest <br />Cher Lead Agency <br />Site <br />gency: <br />WQCB <br />I <br />DISC <br />EPA <br />PL Site' <br />ater Quality Site <br />I <br />10ther Type Site <br />DESIGNATED EMPLOYEE k b , PROGRAM ELEMENT # Z Ct 5�0 CURRENT STATUS <br />NUMBER OF UNITS : 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 Federal laws. <br />APPLICANT'S SIGNATURE <br />AUTHORIZATION TO RELEASE INFORMATION: 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 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />3LA S- <br />\�'1 D <br />✓ <br />X%1 13 <br />L9 <br />