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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 /> r^AGILITY ID # D613 <br /> DD3 1? FACILITY NAME <br /> RECORD ID # D4 D / _/c C1 PRIOR DIST # PRRIIOOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest —Mat Pipeline Invest <br /> Cher Lead Agency SiteAgency: �WQCBJ I DTSC EPA PL Site �ater Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE # D� PROGRAM ELEMENT # G9.5� CURRENT STATUS <br /> NUMBER OF UNITS �f! 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 /> Iv <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INF TION: In addition to the above, when applicable, I, the owner, operator same, of <br /> the property located at a above site address hereby authorize the release of any and all results, ge�� t c N ca and/or <br /> environmental/site sessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HFI DZVI$ *soon as <br /> it is available and at the same time it is provided to me or my representative. QQQv tV\ <br /> CPO," <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2� ?.��• 7- ► 7 () 2 V, Douo5�9�' <br /> � F 10 ENT I A L <br />