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} <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM RE <br /> AUG U 5 1999 <br /> l E�1Vi1=d�Ji N1'---TAL 'r�; ."�,!TF <br /> GENERAL PROGRAM FILE: New <br /> change Edit P46trev �p1'5/.23/94 <br /> 4J <br /> FACILITY ID # FACILITY NAME <br /> fl��-Co►-t :5- NN-tc1iJ< <o� <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest {azMat Pipeline Invest <br /> UIC. / <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site ater Quality Site ther Tape Site <br /> 1 <br /> SNA aisP�6►K- w�-U.. ��C- 3c <br /> DESIGNATED EMPLOYEE # 'l1J PROGRAM ELEMENT # O CURRENT STATUS <br /> NUMBER OF UNITS 1 _i 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 /> JCI I�1 G. VHMK IYAL Oal= AMID ME JQ'MI1CAT W S=CN, SAN D= U:UO rM <br /> SiOQCICI�1, GA. 953 <br /> Title: OFFICER IN 0WIT 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 />