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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 # ! �1 oO�ll Q�IQ FACILITY NAME \.L'"7'i / //�'j, - <br /> RECORD ID # \\P S� �� PRIOR DIST # `�� PRIOR VSWEEPS # <br /> Site Mitigation: E <br /> Environmental Assessment ST/CAP ocal Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency SiteAgency: WQCB DTSC EPA Lite -ter Quality Site I 10ther Type Site <br /> (31o) <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # a CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE : 0 <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 chat 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, operatorpo e $ame, of <br /> the property located at the above site address hereby authorize the release of any and all results, geot'e l �va,1d/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL DIVISION as ;� pon as <br /> it is available and at the same time it is provided to me or my representative. <br /> pU611�NpA iN A RNnE SIGN <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recd By <br /> a � �o`��P� �S�D3 ✓ S917Z 2 � <br /> i � <br />