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SAN JOAQUIN COUNT- PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILZ RECORD FORM <br /> GENERAL PROGRAM FILE: New_7,L�Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # �� /)'[/ � FACILITY NAME <br /> RECORD ID # �1 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: (— - —^ Environmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site 1 e�- WQCn 0TSCT EPA L Site ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # e,4T PROGRAM ELEMENT # 29 �U CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> "lumber 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 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 appli ion and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar State and Federal laws. / <br /> APPLICANT'S SIGNATURE : A� 9:: <br /> Title: Z Date: <br /> AUTHORIZATION T:ated <br /> E INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the propert11s <br /> atthe above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmentassessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is availd 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 a Receipt $ beck # Redd y <br /> 23 2� .oma Q 2� Z <br />