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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MAgTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New ;X: Change <br /> <br />Edit <br /> <br />poo 306 MfAA)2j— <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID # c,.. 1( C)b \C\143 9 FACILiTY NAME ,3-FD CX-3Cli <br />, di 4 a <br />ag(4? <br />RECORD ID # c)i)\1 ) 5 -2_ \:2._ 5 PRIOR 01ST # PRIOR SWEEPS # <br />Site Mitigation: Environmental Assessment UST/CAP Local Hazardous Waste Invest 4azMat Pipeline Invest <br />Other Lead Agency Site Agency, RWQCS DTSC EPA NPL Site Water Quality Site <br />- <br />Other Type Site <br /> <br />DESIGNATED EMPLOYEE # PROGRAM ELEMENT # d, 5-6 CURRENT STATUS <br /> <br />NUMBER OF UNITS : EPA ID #: <br /> <br />INSPECTION CODE : 3 6 6 <br /> <br />Number of TANKS linked to this PROGRAM record : <br /> <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agentof 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, <br /> <br />Date: <br /> <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 />S [S- ,$ 1,5- 4--Atore 55 t4 55 <br />Cat4-4: 1