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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFTLE RECORD FORM <br /> GENERAL PROGRAM FILE: New—&—Change Edit (FRCG4) revised S/23/94 <br /> FACILITY ID # FACILITY NAMEpi/i'f� v!`Q� <br /> RECORD ID # �DOOIZ PRIOR DIST # (• PRIOR SWEEPS # <br /> 1,4k 05/7 //-6-' f <br /> Site Mitigation: ironmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site envy: WQCS OTSC e'PA Site -ter Quality Site I 10ther Type Site <br /> DESIGNATID EMPLOYEE # D PROGRAM ELEMENT # COAAENT STATUS <br /> NUMBER OF UNITS EPA ID #: 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-SRU 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 Farm. <br /> I also certify that I ve prepared this application and that the work to he performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinanc Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> � 1U <br /> Title: DaCe: <br /> AUTHORIZATION TO RELEASE INFORMATION: Ea additi 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 CORY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> �wU- a0 e6 L?7Z <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> aAMV6 �'-�1 c� ✓ <br /> °o <br /> 24D 1 _ <br />