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.r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 # Q 3 FACILITY NAME <br /> ZECORD ID # 5/50 -5 7 PRIOR DIST # 7 <br /> PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site gency: kQCB DTSC EPA L Site ater Quality Site 10 <br /> ther Type Site <br /> DESIGNATED EMPLOYEE 42� PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record L) D S 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> ?HS-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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> .;OAQUIN 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 -ame. of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data anal/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 # Check # Recvd By <br /> �3 �aa� — ✓ �ss3� z <br />