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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES YI r— 1 <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> .F—r- <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> MAY 1729 <br /> 1"N JOA,X N•CCON-Y <br /> PUBUC HEALTH SERVICES <br /> ;E-NERAL PROGRAM FILE: New Change Edit ENVIRORM9ftLRF4*P0DN1817W4 <br /> FACILITY ID # I /T� FACILITY NAME <br /> RECORD 1D # 52 ` PRIOR DIST # PRIOR SWEEPS #( U <br /> -- <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous waste Invest �azMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQCH DISC EPA L Site �ater Quality Site Other Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> :lumber of TANKS linked to this PROGRAM record : <br /> 3ILLING 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 /> =he Masterfile Record information Form. <br /> 1 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: YLCG�YL'Y1 ( ZviC Pe4+. Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 <br /> Date of Payment Payment Type Receipt 4 Check # Recvd 3y <br />