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4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE(: New IV- Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # l 1 J FACILITY NAME /� U T^_ ..O N-_L.T�r <br /> RECORD ID # PRIOR DIST # 'V 1 V�PRRIIOR,STWEEPS # 1 <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: �WQCB I DTSC EPA L Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # Z 1 PROGRAM ELEMENT # 2-CA S-Q CURRENT STATUS <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 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 11 <br /> Title: Date: C%UjNil' <br /> 4NVIkC?Iv!yM .mf:Al SEWcE.S <br /> N <br /> Ai 7M`pV¢SInr <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 —/—/ Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 7-3-J.00 a3y.0o ►��L C6- ✓ �j`11 �c,� <br />