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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: N,,eew/w t Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # I U v I FACILITY "TAME _IA"Ce—vx" 'r C:1,•cJY( //e'+ <br /> RECORD ID # O PRIOR DIST # PRIOR SWEEPS # <br /> JJJ ILA 6 6 E . IC—C--4c , r"A K <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency Site Agency: I �RWQCB I I DTSC I EPA PL Site �Wacer Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE # Z, TPROGRAM ELEME1gT # 1�D CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: 1 INSPECTION CODE : <br /> Number of 'ASKS 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 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 /> Title: Date: �✓ I I <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, geote2cbpical data and/or <br /> !at <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAb 251'06 as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> gy 9 F� <br /> t QUIN('QUNT'f <br /> -'UCL <br /> DEADLINE DATES: Inspection: Current / / Prior / =tJ\ifPJJ�IE'�t;° .' F ITH DIVISIOV <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -2-3`� cn o <br />