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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change Edit <br /> FACILITY ID # t::r A_ ao 13 LI3 7 FACILITY NAME <br /> RECORD ID # 0-5-114/5 q PRIOR DIST # PRIOR SWEEPS <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest —Mat Pipeline Invest <br /> Cher Lead Agency Site P'g <br /> ency: WQC9 DTSC EPA PL Site ater Quality SiteTer Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : V EPA ID #: y 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-EM 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, geotechnicalL"ta and/or <br /> i"P',t ,V,. - <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAITTH"'DIVfSiUW as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> `FP 7 � <br /> Di 1w f+NF AI;H SERVI�F' <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check H Recvd By <br /> X762 <br /> r <br />