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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Y Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # l 3 1 FACILITY NAME L /—,e*Af-5 — e1 U. t . 2 <br /> RECORD ID # 5 a q 44(D PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: 3O Environmental Assessment T/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency SiteAgency: L1qQCB I JDTSC EPA L Site ate- Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE # 1 Q PROGRAM ELEMENT # + � Q CURREN STATUS <br /> NUMBER OF UNITS : Vc� EPA ID #: INSPECTION CODE <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 b billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form_ - <br /> L 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 /> tJ <br /> APPLICANT'S SIGNATUR5 <br /> Title: Date: i <br /> AUTHORIZATION TO RELEASE INFORMATION: addition to the above, when applicable, I, the owner, operato��la�Na <br /> 1ss me, of <br /> the property located at the above sit address hereby authorize the release of any and all results, geoiCta <br /> environmental/site assessment info tion to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVZSJCf)84 ?-- as <br /> it is available and at the same sit/ <br /> it is provided to me or my represetative. (V� <br /> SA�L��4A H�L�HpV1510N <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> zfo r <br /> 6C.0 5 zq-o Z 2,11 <br />