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SAN JOAQUIN CCU= PUBLIC HEALTH SERVICES g <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM AUG 05 1999 <br /> `NVI�?(JNfl/EN I/n:°__ HE" <br /> PERMIT / Q'-g ICE. <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/.231/94 <br /> FACILITY ID # O FACILITY NAME <br /> J ---'�2641,120 CA- <br /> RECORD ID # J 4 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste invest azMat Pipeline Invest <br /> UIL <br /> ther Lead Agency Site gency: �WQCB DTSC EPA L Site �ater Quality Site 10 <br /> ther Type Site <br /> S4(AUOLZ ISP ►�— <br /> DESIGNATED EMPLOYEE # 'll 1 PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS I l r 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 be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record 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 /> 41 JCgI[�G. VHKW NAVAL CX1`R= AND TFT FC T 1k 1f GATICNS S=C N, SAN D= DEEAM�IFNT' <br /> S10=, CA. 95203 <br /> Title: OFFICER IN C A CE Date: 6/10/99 <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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 23� <br />