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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 X Change Edit (PROG4) revised 5/33/94 <br /> FACILITY ID MFACILITY NAME <br /> - 5 D Lifetile <br /> RECORD ID 4 150 / PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental AssessmentUST/CAP Lccal Hazardous waste Invest �a2ftt Pipeline Invest <br /> O <br /> they Lead Agency Site gency: F-QCB <br /> DTSC EFA L Site later Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # C�)(J PROGRAM ELEMENT 0 �q S� CURRENT STA US <br /> NUMBER OF UNITS I l EPA ID 0: I INSPECTION CODE <br /> Number of TANKS linked to chia PROGRAM record N/A <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly chargee 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 /> JWC71N COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> x APPLICANT'S SIGNATURE <br /> �iCle:—t✓x -Ecfy�-VS1� ryyl� ��/ 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, 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 Type Receipt k Check # Recvd By <br /> n7 � �7 3 � <br /> 1 'd 00LO 956 60Z ON SJV WOdd WdSF: 1 5661-S1-9 <br />