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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 # AGILITY NAME <br /> RECORD ID # ///�/ �,( O C��7�I /�Ck PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest at Pipeline Invest <br /> other Lead Agency SiteAgency: WQCB DTSC EPA L Site ater Quality Site Flhe Type Site <br /> 316 <br /> 135 Q <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: V 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 that I have prepared this application nd that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, Stat�d Federal laws. <br /> APPLICANT'S SIGNATURE <br /> ell <br /> Title: Date: <br /> AUTHORIZATION TO RELEASEORMATION: 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 /> 7117 <br /> CONFIDENTIAL <br />