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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: NewChange Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # `D 0 f -7 S' FACILITY NAME Z � <br /> RECORD ID # 4l p�a,�p� / PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessmen ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQCB DISC EPA L Site �ater Quality SiteF Cher Type Site <br /> /' 310 <br /> SG� - <br /> )I Z <br /> �3� 5 <br /> DESIGNATED EMPLOYEE # rn ' ( PROGRAM ELEMENT # Z(_SO CURRENT STATUS <br /> NUMBER OF UNITS C EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 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: 02 e: <br /> AUTHORIZATION TO RELEASE INFORMATION: In a i ion to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above si ddress hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment ormation to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at t 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 Typ Receipt # Check # Recvd By <br />