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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFIL^c RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change <br /> Edit <br /> FACILITY ID # DOJ Al T —1 3 LI FACILITY NAME <br /> RECORD ID # <br /> 7 -7 FACILITY <br /> PRIOR DISI # PRIOR SWEEP <br /> �R n L/ n <br /> its Mitigation: �. Environmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> then Lead Agency Site envy: WQCB DISC EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLJYEE # D� PROGRAM ELEMENT # 2�J{./ CURRENT STATUS <br /> NUMBER OF UNITS <br /> EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record V 51D <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-ENDS 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 RMATION: In addition to the above, when applicable, I. the owner, operator or agent of same, of <br /> the property located a e above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site sessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available d 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 Receipt # Check # Recvd By <br /> 26�° � I21 03t V, <br /> jp 1/24 <br /> a� " <br />