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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 # r*V O I�/ /T FACILITY NAME <br /> RECORD ID 9 0�,(�o Sago �`- PRIOR DIST 4 PRIOR SWEEPS # <br /> �{ l0 W - L--ov&cs-< 4-v� , L.G�'f� vop <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest f <br /> Cher Lead Agency SiteAgency: I IRWQCB DTSC EPA kL Site ater Quality Site they Type Site <br /> (310) <br /> DESIGNATED EMPLOYEE # Z l TPRZ ELEMENT $ Z��O CURRENT STATUS <br /> —T� <br /> NUMBER 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 ?ARTY 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 / i Prior <br /> Fee Amount Amount ?aid Date of Payment Payment Type Receipt # Check # Recvd By <br /> APIA- <br /> Io�zZ1a3 <br />