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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> •:'f1. <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GEnRAL PROGRAM FILE: New Change Edit <br /> A / f SPROG4y revised 5/23/94 <br /> it FACILITY ID # /X 7y-02 FACILITY NAME /J�77? � rfj} /1/ , , ti S <br /> f <br /> klAy <br /> •fir <br /> RECORD ID # RR �O �� PRIOR DIST # <br /> PRIOR SWEEPS # <br /> . <br /> . <br /> Site Mitigation: Environmental AssessmentST cal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency SitE gency: WQC8 DTSC EPA PL Site ater Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE U `{AJ/ PROGRAM ELEMENT q 1�Z �I/ CURRENT STATUS <br /> x NUMBER OF UNITS EPA ID #r ` <br /> INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record r <br /> ;BILLING ACKNOWLEDGEMENT: I, the undersigned owner: operator or agent of same, acknowledge that all site and/or project specific x <br /> PHS-END hourly charges associated with this facility or activity will be billed t0 the party identified as the BILLING PARTY on <br /> z the Masterfile Record Information Form. <br /> ;:F2 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> u JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. `r"I <br /> w (9( <br /> 1 <br /> -1 <br /> 31PPLICANT'S SIGNATURE :''✓� <br /> rtf <br /> 'Title. <br /> Dater, - <br /> F AEMORIZATION TO RELEASE INFORMATION: In addition to the above,' when applicable; 1, 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 /> �9 environmental/site aaseasmsnt information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISMI as soon as <br /> it is available and at the same time it is provided to me or my representatives <br /> t DEADLINE DATES: inepcctioni Current / / '" Prior <br /> " Fee Amount /mount Paid' Date ok Payment•':-. Payment Type. Receipt # .Check #, , Recvd By <br /> X313.: 7. <br /> Z <br /> 11ng <br /> j� <br /> � +' i s'i r 4 a? t 1 Z •i1 r� �e � .,- i•:`� <br /> — �• -.� CJs <br />