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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> �pRpG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE:: 'l New�Change Edit L !\ <br /> FACILITY ID 4 ' rl DVI b z'a'q / FACILITY NAME C 1 b• 1 !J C `� <br /> RECORD ID k Pio �2� PRIOR DIST k PRIOR.SWEEPS M <br /> ite Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Iest <br /> Cher Lead Agency Site envy: �' WQCB DISC EPA L Site aver Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # LL 8 U PROGRAM ELEMENT K �� �js CURRENT STATUS }� <br /> NUMBER OF UNITS : T EPA ID #: INSPECTION CODE 3 lJ <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-ERD '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: Date: <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 /> �ivtr_ a � 3ysSS <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Data of Payment Payment Type Receipt 4 Check 4 Recvd By <br /> �� 9 '&3 <br />