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v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: NewwChange Edit ((PR/OG4) revised 5/23/94 <br /> FACILITY ID # 0/a D Q FACILITY NAME <br /> RECORD ID # rS O✓ PRIOR DIST # Vel' PRIOR SWEEPS # <br /> Site Mitigation: X Environmental Assessment ST/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site (, Agency: IRWQCB DTSC EPA PL Siteater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEET# &UPROGRAM ELEMENT # 2q.SQ CURRENT STATUSNUMBER 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 that I have prepared this application and t the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State Federal laws. <br /> APPLICANT'S SIGNATURE <br /> d <br /> Title: Date: <br /> MAY 251 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator zlpr.agein,si,ir;9 s of <br /> the property located at the above site address hereby authorize the release of any and all results, Na THr)' <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 /> ,vv o <br /> DEADLINE DATES: Inspection: Current -/-/ Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 23� 3Z 3 . 5z ✓ Z 2 3�o C <br />