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SAN JOAQUIN. COUNTY PUBLIC H —i �'LRVICES <br /> eWIRONME`rrAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> l <br /> GENERAL PROGRAM FILE: New Change edit D rev <br /> FACILITY ID # (}� FACILITY NAME �/S A i o( , tf/`Q�Y4�� <br /> p n O O I? (/ PRIOR DIST # PRIOR SWEEPSJ <br /> RECORD ID # �-�J l T <br /> Site Mitigation: <br /> Environmental Assessment ST/CAP cal Hazardous Waste Invest az.Mat Pipeline Invest <br /> other Lead Agency Site Agency: <br /> WQCg DISC EPA L Site ater Quality Site then Type Site <br /> ?ROGRAM ELEMEN'i' # tet"'I . � v ��-R-`�T STATUS <br /> DESIGNATED EMPLOYEE:OE� VVV CL <br /> NUMBER OF UNITS : <br /> EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this ?ROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: i, rhe undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> ?HS-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 Informac'_en 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 /> Date: <br /> Title: <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 HvAL7A SERVICES `.;VIRONMEo CAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> / Prior <br /> PDEADLINES: Inspection: CurrenC / Pa c e Receipt # C`neck # Recvd By <br /> Amount PaidDate of Payment Y �!P <br /> �� io/�>a fdr3. <br />