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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM c ���jjj <br /> GENERAL PROGRAM FILE: New ✓ Change Edit '3 -7 q a d ` . ROG/41 revised 5/23/94 <br /> FACILITY ID # rA c o 9'9'93 1 <br /> FACILITY NAME / _r Com.... <� `a <br /> RECORD ID # ` 5�-���] PRIOR DIST # `7 PRIOR SWEEPS # <br /> 54�e Mitigation: vironmental AssessmentST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site envy: ITTI <br /> DISC EPA L Site -ter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # '�'1 PROGRAM ELEMENT # a� �i� CURRENT STATUS (� <br /> NUMBER OF UNITS : 111 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 /> 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 Receipt # =heck 4 3ecvd 3y <br /> JL4 ► b3 6 v �c <br />