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DESIGNATED EMPLOYEE 4 av-/ PROGRAM ELEMENT # 30. 3D CURRENT STATUS <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <br />Number of TANKS linked to this PROGRAM record : <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New ‘*/!: Change <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID # KA-0 0 111 -7 Li- FACILITY NAME "ocp3/4/7v5 aaft <br />RECORD ID # ILO c24,02 cq PRIOR 01ST # PRIOR SWEEPS # <br />C- <br />Site Mitigation: Environmental Assessment UST/CAP )( <br />be <br />Local Hazardous Waste Invest AazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB: DTSC EPA NPL Site Water Quality Site Other Type Site <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 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 /> <br />Tile: <br /> <br />Date: <br /> <br />AUTHORIZATION TO RELEASE I RMATION: In addition to the above, when applicable, I. the owner, operator or agent of same, of <br />the property located at e 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 Receipt 4 Check 4 Recvd By <br />2;11 2/747 96/-2-- Ctak, <br />74 573110