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w SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: Ne-41 <br /> ew Change Edit <br /> (PR <br /> OG4) revised S/23/94 <br /> FACILITY ID # 0 <br /> 0 <br /> l0 FACILITY NAME q:7J <br /> RECORD ID # PRIOR DIST PRIOR SWEEPS <br /> # <br /> site Mitigation: ironmental Assessment [IST/CAP tical Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQCB I I OTSC I I EPA I L Site -ter Quality Site I 13ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # ;2-1 <br /> J M LJ s CURRENT STATUS J <br /> NUMBER OF UNITS : 1 EPA TO #: - 1. INSPECTION COD£ <br /> Number of TANKS linked to this PROGRAM record <br /> h <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 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 /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or apgepnt f $ap(grtof <br /> the property located at the above site address hereby authorize the release of any and all results, geotecM3cdP C)V 1� <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> .� ' ` NOV �I 7 2000 <br /> Ute'/ ! 6 D-�r SPUSLICC HEEE&TH A RH p STOP! <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check 9 Recvd By <br />