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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change c^dit (PRCG4) revised 5/23/94 <br /> FACILITY 1D & 6� DDSS "'AGILITY NAME � ��/I ^&4 y k <br /> RECORD ID # pip 5 3 l 3 5 PRIOR DIST p J LLL PRIOR SWEEPSS( + <br /> Site Mitigation: Environmental Assessment ST/CAP ocal Hazardous Waste Invest azMat Pipeline invest <br /> Other Lead Agency Site !, Agency: WQCg DISC EPA L Site ater Quality Site then 'We Site <br /> DESIGNATED EMPLOYEE k Qq-2 PROGRAM ELEMENT R ��• ` D CURRENT STATUS. <br /> NUMBER OF UNITS. : (( EPA ?D q: ✓ 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 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 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 /> 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 Payment Payment Type Receipt Y Check S Recd By <br /> 3 � 3 SFS i <br /> 1,4W� 1910 Sg�F <br />