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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> New /Change_Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: Ne <br /> FACILITY ID # FACILITY NAME !)j/A/ 4/�. l/ <br /> RECORD ID # PRIOR DIST # 'v PRIOR F)SG` (WEEEEPPS # <br /> Site Mitigation: J( nvironmental Assessment ST/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site (� Agency: �WQCB DTSC EPA L Site ater Quality Site they Type Site <br /> 1 3/5 <br /> DESIGNATED EMPLOYEE # �9T <br /> PROGRAM ELEMENT # `Ti�6 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 me, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activit" 1 be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record information Foran. <br /> I also certify that I have prepared this apa itit o� that the work to be nerfozmed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Stan ds, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date- <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 Amount Amount Paid Date of Payment Payment Type W, 4 Check # Recvd By <br />