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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.N Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # f1 C/ A) <br /> 1 / FACILITY NAME O�� � �s IAJ e <br /> RECORD ID # wR D 5 1 g g b PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency Site gency: <br /> LWQCBrXFS EPA L Site �acer Quality Site they Type Site <br /> —T—` <br /> DESIGNATED EMPLOYEE # &Q PROGRAM ELEMENT # Z9,�� 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 chat 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 ORMATION: In addition to the above, when applicable, I, the owner, opepa r or agent of same, of <br /> t�' 7 � <br /> the property located a the above site address hereby authorize the release of any and all resultsnn call data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES rNVIRONMENTAL bIVTSiON as soon as <br /> it is available and at the same time it is provided to me or my representative. n r P 2 7 2002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> FNV1R0NMFtJTAi "[-,i <br /> DEADLINE DATES: Inspection: Current / / Prior —/—/ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />