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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New—_-�'/Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # f� (\ \ 5 I FACILITY NAME /Lp A Na/ Axexe G/4 /26 S <br /> RECORD ID # O S2_I q\ \p PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency Site gency: WQCB I DISC EPA L Site .ter Quality Site I 10ther Type Site <br /> 3io <br /> Sc L <br /> sus <br /> DESIGNATED EMPLOYEE # D 6Q PROGRAM ELEMENT # Z f 76 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 /> PHSi 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 <br /> /and,Federal laws. <br /> �V <br /> APPLICANT'S SIGNATURE y!/✓� <br /> Title: Date: <br /> I <br /> AUTHORIZATION TOINFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property loco d 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 Dace of Pa C P enc Type eceipt # Check # Recvd By <br />