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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 <br /> {PROG4) revised 5/23/94 <br /> FACILITY ID # O 01'1- <br /> '1 o 6 FACILITY NAME tiff AJ u�Y /} <br /> RECORD ID # D !v/_l/p3 PRIOR DIST # 1 PPRR,IOR SWEEPS # <br /> Site Mitigation: Y_Environmental Assessment T/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQC$ DTSC EPA L Site �ater <br /> Quality Site 1 . 10ther Type Site <br /> DESIGNATED EMPLOYEE # �C! PROGRAM ELEMENT }# CMZRENT 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 ox 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 /> AUTHO ZATION TO RELEASE I ORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the pro erty located at he above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environme 'al/site a essment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available a 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 # Check # Recvd By <br />