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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISI0.11 <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> =4ERAL PROGRAM FILE:' New C.`.aage Edit - (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> SCC++n`^avtttio rrd eV' Les <br /> RECORD ID # PRIOR DIST # PRIO'R LLSWEEPS # <br /> site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest � �1at Pipeline Invest <br /> Other Lead Agency Site gency: WQCB DTSC EPA L Sit_ ater Quality Site ther Type Site <br /> DESIGNATED LMPLOYEE # 1C7-2- 7 PROGRAM ELr-MM;T '# �L-ck 15 Q CURRENT STATUS <br /> 'TUM'ER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROD-,J,4 record <br /> BILLING ACFOWLEDGEXENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> ?HS-E&D 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 S;,v <br /> JOA(YUIN CCU= Ordinance Codes and Standards, Sta d Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: ���1]ld�lCi i` _ Date: /6) -6 -9 9 <br /> AL"I"SCRIZATION TO RELEASE INFORMATION: In addition to'the:above, when applicable, I, the owner, operator or agent of same, o: <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 XZALTd SERVZC=S ENVIRONNMNTAL HEALTH DIVISICN as Stan as <br /> it is available and at the same time it is provided to me or my representative. <br /> D=ADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2-3q.cc <br /> A <br />