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, r <br /> c ' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New ZiChange Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # O C O FACILITY NAME `� !2, r D <br /> RECORD ID # �7 0 Q O PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest —Mat Pipeline Invest <br /> Other Lead Agency Site Age7. 7WQCB DISC EPA L Site �ater Quality Site �ther Type Site <br /> 3<0 <br /> S��3iZ <br /> l 3�5 <br /> DESIGNATED EMPLOYEE # D�O PROGRAM ELEMENT # �( ir/ O CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 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 en ified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application an t work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State F eral 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 />