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i <br /> I <br /> FS <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONM1MTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILB RECORD FORM <br /> GENERAL PROGRAM FILE: New Change I Edit IPROGO revised 5/23/94 <br /> FACILITY ID # V�/x`(94 FACILITY NAME G� _-7S <br /> I <br /> RECORD ID # 0 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Asses—+T/CAP Local Hazardous Waste Invest [UzMat Pipeline Invest <br /> %her Lead Agency Siteency: C8 17TSC EPA site -ter Quality Site the= Type Site <br /> I' <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # Z gi�(J CURRENT STAINS <br /> b <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKROWLF.DGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associat with this facility or activity will be billed to the party identified as the BILLING PARTY an <br /> the Masterfile Record Information rm. <br /> I also certify that I have prepared s application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and S State and federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: r Date: <br /> I <br /> N <br /> I <br /> AUTHORIZATION TO RELEASE F'ORMATION: In addition to the above, when applicable, I. the owner. operator or a EE <br /> the property located at the above site address hereby authorize th elease of any and all results, geot data and/or <br /> environmental/site assessment information to SAN`SOAQaIN COUNTY PUffi,IC TH SEDtVICES ENVIRONKENTAL HEALION%�. s <br /> it is available and at the same time it is provided to me or my representative. VU <br /> SAN Jt?gQU1N <br /> Co <br /> Fnvi'gop"t IE AALLiCFH SEWry <br /> IEFl 1R�ES 0'J <br /> DEADLINE DATES: Inspection: Current. / / Prior <br /> I' <br /> Fee Amount Amount Paid Date of Payment Payment Receipt # Cheek # Recvd By <br /> z1bea FZ' (W:, <br /> I <br />