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SAN JOAQUIN COUNTS PUBLIC HEALTH SERVICES <br /> ENVIIiONMENTAL HEALTH DIVISICN <br /> SITE MITIGATION MASTERFILE RECORD <br /> GENERAL PROGRAM FILE: New Change Edit (PRCG4) revised S/23/94 <br /> FACILITY IO # FACILITY SAME <br /> M A.c-4 m ( ALC-1-D <br /> RECORD ID # PRIOR OM # PRIOR SWEEPS # <br /> \ <br /> site Mitigation: /�V 'ronmental Assessment Invest <br /> /CAP al Hazardous waste zMat Pipeline Invesc <br /> [her Lead Agency Site / enry: wQCB DTSC EPA L Site star Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # p Z PROGRAM ELEMENT # 9 S'b CORP= STATUS <br /> NUMBER OF IINITS EPA TO #: 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 [his 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 SIGATURE <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 /> envLronmental/site assessment information to SAN JOAQUIN COMM PUBLIC HEALTH SERVICES ENVII20194ENAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is pravided 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 /> IS L(,CPO <br />