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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> w Chan Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: Ne a g <br /> FACILITY ID 4 f�O 1 Q 2 1 FACILITY NAME C11-5 <br /> / <br /> RECORD ID # O U PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest —Mat Pipeline Invest <br /> other Lead Agency SiteAgency: �WQCB DISC EPA L Site �ater Quality Site �ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # L9 t5-44CURRENT STATUS <br /> NUMBER OF UNITS : (/ EPA ID #: INSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: 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 cc 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 /> VVI <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE I RMATION: 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 Receipt # Check # Recvd By <br />