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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> IXX ^ 1`\ <br /> GENERAL PROGRAM FILE: New FACChange Edit V I J 1[ (PROW revised 5/23/94 <br /> [FACILITY ID # Q 0 1 ie, FACILITY NAME �!t�vy <br /> RECORD ID # v l�•-y PRIOR DIST # I (/ PRIOR SWEEPS 4 l/ <br /> Site Mitigation: Environmental Assessment ST/CAP ocal Hazardous :caste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQCB I I DTSC I I EPA I L Site I ater Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # '�I I / PROGRAM ELEMENT # �''I s v CURRENT STATUS / T <br /> NUMBER OF UNITS : l EPA ID #: IIf -SECTION CCDE Iy <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 no the parry Iden ified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify chat 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 SERVICESENVIRONMENTAL 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 Receipc # —heck # Recvd By <br /> —Zl- <br /> � 61�r1�s� <br /> ( AN 13Lf3-7-7 <br />