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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: NewChange Edit (PROG4( revised 5/23/94 <br /> FACILITY ID # A Q QII IS d-- FACILITY NAME E� A�C <br /> RECORD ID # `a 3 U, ! PRIOR DIST # '` PRIOR SWEEPS # <br /> Site Mitigation: v nvironmental Assessment T/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site n gency: WQCB DTSC EPA L Site I ater Quality Site 10ther Type Site <br /> 731(3 <br /> SC'. 't12- <br /> 51!5 <br /> IZ51 <br /> DESIGNATED EMPLOYEE # D 6 8 PROGRAM ELEMENT # 2q.SQ 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 orepared 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: 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, C:rrent / Prior <br /> pee dmount Amount Paid Cate of Payment Payment Type Receipt # Check # Recvd By <br /> L �I ��a2I5 ✓ 3 z I oto I Cw�c <br /> Z✓ 10(Or <br />