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VESAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �'.«•— <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM AUG 05 1999 <br /> PERMIT / SERVICE. <br /> GENERAL PROGRAM FILE: New n—Change_Edit <br /> �,.(PROG4) revised 5/.231/94 <br /> FACILITY ID # 1 1 FACILITY NAME " 6" ` wMcic ��� (�1✓ <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS If <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> they Lead Agency Site gency: WQCB DTSC EPAF L Site ater Quality Site Cher Type Site <br /> 0) <br /> DESIGNATED EMPLOYEE It -�iJ- PROGRAM ELEMENT_# CURRENT STATUS <br /> NUMBER OF UNITS : 1 �v11 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 /> AIN G. VIII I )IAL 02R= AMID TELMM ICA'IIGS S=CN, SAN DIEM LELAHNM <br /> S1= 53 <br /> Title: CMCM IN QHRE Date: 610/99 <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 />