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SAN JOAQUIN COUNTS PUBLIC TH SERVICES <br /> ENV <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SIT£ MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit ` (PROG4) revised 5/23/94 <br /> y / / <br /> rACILITY ID # 1 �/ 'D v PACILITY NAME <br /> RECORD ID # <br /> 'SCJ PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous waste Invest azMat Pipeline Invest <br /> Other Lead Agency Site gency: WQCB DTSC EPA L Site ater Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE I PROGRAM ELEMENT # v l CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE : 3�a <br /> '�12- <br /> N, her <br /> 2Number of TANKS linked to this PROGRAM record 3!I;i <br /> BILLING ACKNOWLEDGEMENT: 1, 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 t work to be nerformed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and F ral laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INF TION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at 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 Paym Paymennt''//Type Receipt # Check # cd By <br /> I ;.' <br /> o lam! VW -\ <br /> � `t13Z(oS <br />