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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 # S� �9 FACILITY NAME &�� �//� l c <br /> RECORD ID # P1LCJ`+ ��?�10 PRIOR DIST $ PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: �RWQCBDTSC EPA kL Site �ater Quality Site they Type Site <br /> U,l.0 . <br /> 10 ' 315 <br /> DESIGNATED EMPLOYEE # O In S PROGRAM ELEMENT # 3O 3(D CURRENT STATUS <br /> NUMBER OF UNITS F� EPA ID #: INSPECTION CCDE <br /> ;lumber 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 /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Fe aw . <br /> APPLICANT'S SIGNATURE : <br /> Title: Date: <br /> AUTHORIZATION TO RELEASZ 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # '._heck # Recvd By <br /> q-17• oma( �Zo1 A —7— <br />