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SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM / <br /> v <br /> GENERAL PROGRAM FILE: New—y—Change Edit (PROG4) revised 5/23/94 <br /> r <br /> FACILITY ID # 14,3 9-'3 FACILITY NAME 3 m a 1) <br /> RECORD ID # Sa�{3 g PRIOR DIST # 7 PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest —Kat Pipeline invest <br /> then Lead Agency Site gency: �WQCBJ DTSC EPA L Site �ater Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # leo 01/5 CURRENT STATUS <br /> l � <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE :_T <br /> :lumber of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: I, the andersigned 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 chat I have prepared this application and chat 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 /> s7 r <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />