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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 # �!1 5 FACILITY NAME <br /> RECORD ID # 11 PRIOR DIST # PRIOR SWEEPS # <br /> 19,411 <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest kzMat Pipeline Invest <br /> Other Lead Agency SiteAgency: WQCB DTSC EPA L Site �ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # I Tkn PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: 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 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 /> J��fr�� <br /> AUTHORIZATIO RELEASE INFORMATION: In addition to the above, when applicable, Z, the owner, operator `o�\v' ame, of <br /> the property located at the above site address hereby authorize the release of any and all results, got \vq�u" data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL 14 P& DIVISZ soon as <br /> it is available and at the same time it is provided to me or my representative. wt�n 4 <br /> N Jo g\�� Popo <br /> �N <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />