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A '\ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: ,,/�f New Change Edit (PROG4) reviised�5/23/94 <br /> FACILITY ID # //7/// �'S 9 3 7 FACILITY NA[+Lw ip <br /> RECORD ID # X/Y /Do�� PRIOR DIST k �PR�,IJOORR�SWEEPS # K7�J <br /> Site Mitigation: nvironmental Assessment T/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQCB DTSC BPA L Site ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # c o o PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: I VV 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 /> 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 preps this plication and t the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Cod and St dards, State an ederal laws. <br /> APPLICANT'S SIGNATURE . <br /> Title: V c_ 1 2 Date: <br /> AUTHORIZATION TO RELRASE 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 /> %ivv . aa �a �s <br /> DEADLINE DATES: apection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2 3 , 2V% <br />