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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 # (� �O` Q '3 D FACILITY NAME ��/l�t�� �� r� FS <br /> RECORD ID # 1� n tj��i ` PRIOR DIST # PRIOR SWEEPS # <br /> 1 V D <br /> 10 141 4�3 .5- HggaL A) n � FC <br /> Site Mitigation: environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency SiteAgency: �WQCB DISC EPA L Site ater Quality Site 1-7;;e Site <br /> DESIGNATED EMPLOYEE # 6 Z( PROGRAM ELEMENT # Z R 5� CURRENT STATUS <br /> VUMBER OF UNITS 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 /> Title: Date: <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 /> oo J b io-� q-c-c,7-- �.o <br />