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1 <br /> SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES FILE C <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE• <br /> New M Change Edit ;PROG4y revised 5/23/94 <br /> FACILITY ID # FACILITY NAME (631 IT L ,4*A f- <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> X site Mitigation:3O environmental Assessment T/CAP cal Hazardous Waste Irivest zMat Pipeline Invest <br /> s <br /> Other Lead Agency Site ency: WQCB DISC EPA kL Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # a Lu PROGRAM ELEMENT # . 3 O CURRENT STATUS <br /> NUMBER OF UNITS V 1EPA ID 9: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent be <br /> 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 MasterfileRecord Information Form. <br /> I also certify that 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: addition to the above, when applicable, I, the owner, operator or agent.of same; of <br /> the property located at the above sit address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment info tion to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL, HEALTH DIVISION as soon as <br /> it is available and at the same me 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 # Rec�vd By <br />