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i <br /> l <br /> bot, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION' <br /> SITE MITIGATION MASTERFILE11 <br /> RECORD FORM <br /> i <br /> I <br /> GENERAL PROGRAM FILE:( New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # V� FACILITY NAME <br /> RECORD ID # 6DI �11 <br /> PRIOR DIST # �J Q <br /> PRIOR SWEEPS # (/` <br /> 1 <br /> I� <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> i <br /> ! <br /> ther Lead Agency Site Egncy: WQCB DTSC EPA L Site �ater Quality Sit IDther Type Site <br /> i <br /> DESIGNATED EMPLOYEE # x PROGRAM ELEMENT # �� 'j� CURRENT STATUS + <br /> �+ ✓ <br /> NUMBER OF UNITS EPA ID #: 1 INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record d <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> 7 <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 <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, a and Federal laws. <br /> APPLICANT'S SIGNATURE i <br /> i <br /> i <br /> Title: Date: it <br /> 1 <br /> I <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operato MMI"ame, of <br /> the property located at the above site address hereby authorize the release of any and all results, ge. ##��33d�Lyand/or <br /> �a <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 61VISIOO(N�as soon as <br /> it is available and at the same time it is provided to me or my representative.; J(-{ - 6 1998 <br /> SAN JOAQUIN COUNTY <br /> i PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment a ;;Receipt # Check # Recvd By <br /> ! <br /> ��.�-q � . <br />