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PAYMENT <br /> RECEIVED <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0 C T 3 1 2005 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM VS�ANUIN COUNTY <br /> NMENTAL <br /> OwlEPARTMENT <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # n (� L ' b S� FACILITY NAME 1C r <br /> RECORD ID # P Q Ste{ 6-I I PRIOR DIST # D\ PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: I IRWQCB DTSC EPA kl, Site �ater Quality Site F Fther Type Site <br /> DESIGNATED EMPLOYEE # F �14 PROGRAM ELEMENT # ZS CURRENT STATUS /l <br /> NUMBER OF UNITS 1 EPA ID #: INSPECTION CODE V <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 /> 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 /> DEADLINE DATES: Inspection: Current / / Prior / / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />