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t\\ �-/� • • <br /> V \ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> J <br /> Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: '� New Cha49e / <br /> FACILITY ID # 00/33 F� FACILITY �w/..e.^�o� ry�✓j � , <br /> RECORD ID # �RaSl73 7 7 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: 9,vironental Assessment T/CAP <br /> cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site Agency:: WQCB DTSC EPA L Site star Quality Site hex Type Site <br /> DESIGNATED EMPLOYEE # 2 PROGRAM ELEMENT # ?j9� D CORRENT STATUS <br /> NUMBER OF UNITS <br /> 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 /> XAP <br /> JOAQUI COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> CANT'S SIGNATURE : <br /> Date: <br /> Title: <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 SERVICS ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> -Z vv. o()8s�is <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> By <br /> Fee Amount Amount Paid EDatef Payment Payment Type Receipt 4 Check # Recvd <br />