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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 Change Edit ` (PROG4) revised 5/23/94 <br /> -FACILITY ID # SD 0! 63 FACILITY NAME I1 fn <br /> D <br /> RECORD ID # /� O PRIOR DIST # PRIOR/S'WWEEEPPS'#r <br /> pR ,�Say3C? <br /> Site Mitigation: nvironmsntal Assessment IUSTICAP cal Hazardous Waste InvestzMat Pipeline Invest <br /> Xthey Lead Agency Site gency: X WQCB DISC EPA L Site ater Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # 6(00 1 PROGRAM ELEMENT # 2 1i�5 1 <br /> CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> � 3lb <br /> Number of TANKS linked to this PROGRAM record 3 1� <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 Nave 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 /> (v <br /> APPLICANT'S SIGNATURE <br /> Title: I 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 /> 40 11 <br /> DEADLINE DATES: Inspection: Current / / Prior _/_/ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2033 Cv�- <br />