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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 Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # t -�� FACILITY NAME V(CTD(L 1/ =51-4/-,)13 f4R)U5 <br /> RECORD ID # ') �r� 3 PRIOR DIST # PRIOR SWEEPS # <br /> 2 t n o a mc"Cta y <br /> Site Mitigation: vEnvironmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: �RWQCB DTSC EPA L SiteT -ter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # fo [9 PROGRAM ELEMENT # I Zl G�;C) CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> .lumber 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 chat 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: In addition to the above, when applicable, I, the owner, operator or "ISdN� <br /> aa�Te, of <br /> the property located at the above site address hereby authorize the release of any and all results, geot d'"d/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL soon as <br /> it is available and at the same time it is provided to me or my representative. A r k <br /> $ LUUd <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DE <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd/ ,By <br /> Cly I v o A72- <br />