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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 # FACILITY NAME <br /> t'� ��� �� <br /> RECORD ID # ?RIOR DIST # PRIOR SWEEPS <br /> 4� 9C1 ��AL117,1,-t �e L/ <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous :taste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site Agency: �WQCB DTSC EPA �PL Site -ter Quality Site Cher Type Site <br /> 0 <br /> DESIGNATED EMPLOYEE # ^f 1 Tp <br /> ROGRAM ELEMENT # jj /� CURRENT STATUS <br /> C� <br /> NUMBER OF UNITS EPA ID #: :NSPECTION 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 /> ?HS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING ?ARTY 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 /> 3;d -0 a9It�I? <br /> DEADLINE DATES: Inspection: Current / / Prior -/-/ <br /> Fee Amount Amount ?aid Date of Pavment Payment Type Receipt # deck # Recvd By <br /> Z6�..aC) 7•0 0L10038' <br />