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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 S/23/94 <br /> FACILITY ID # FACILITY NAME p-e Nz/A--16,e-S <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS <br /> 1 3 y3o <br /> Site Mitigation: vironmental Assessment ST/CAP 6ocal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: �WQCB DTSC EPAPL Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # 6 Z el PROGRAM ELEMENT # a �(� CURRENT STATUS <br /> ,LUMBER 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 /> PAYMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agetR E"Ff\/E!D <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 DIg�9�p ff as X004 <br /> it is available and at the same time it is provided to me or my representative. J{� L v <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />