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• � Kl/ :A `vi( <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES e� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME C I J��T l A!� 1 <br /> I_0014 ) 103 <br /> RECORD ID # �rj 1r s7 1 -7 <br /> PRIOR DIST # J PRIOR SWEEPSI#v`— 'v <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest —Mat Pipeline Invest <br /> Other Lead Agency Site genay: WQCB DISC EPA L Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # g,5 <br /> PROGRAM ELEMENT # Z9661 <br /> CURRENT STATUS !!�� <br /> NUMBER OF UNITS ( EPA ID #: INSPECTION CODE J �� <br /> .lumber 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 Z 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 spme, of <br /> the property located at the above site address hereby authorize the release of any and all results, geote i� \\a /or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALAY'ON 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 /> N`�\RAN <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 17 if 3(, <br />