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DESIGNATED EMPLOYEE # q PROGRAM ELEMENT # CURRENT STATUS <br />NUMBER OF UNITS : <br /> <br />EPA ID #: INSPECTION CODE : <br /> <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 S' Change <br /> <br />Edit <br /> <br />wArE,A. 4- <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID # f..2)....1 c: G b c) \ri <br />8 <br />FACILITY NAME 315;;AltiA-IN es2.-d . , ,_ .. <br />RECORD ID # <br />c? Ck 0 2 6 3 6 \ 1-' PRIOR DIST # PRIOR SWEEPS 4 <br />"It_e Mitigation, Environmental Assessment UST/CAP Local Hazardous Waste Invest HazMat Pipeline Invest <br />//Other Lead Agency Site Agency: 2( RWQCB FTSC EPA gPL 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 />P115-END 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: <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, 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 Type Receipt # Check # Recvd By <br />;1-- '35 ! D I