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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> r <br /> GENERAL PROGRAM FILET New ^C}�n9e edit <br /> (PROG4) rev#sed 5/13/94 <br /> PACILITY IDN /� / FACILITY NAME t_g:" M�-n-L�_ pPePL-P--�/ <br /> RECORD rD N ' PRIOR DIST N PRIOR SWE6P5 N <br /> Site Mitigation: Environmental Assessment T/CAP Local Hazardous waste Invest azMat Pipeline Invest <br /> then Lead Agency Site �\ ency: HQCB DISC BPA PL Site �ater Quality Sita they Type Site <br /> f <br /> ti DESIGNATED EMPLOYEE JI Q PROGRAM ELEMENT N CURRENT STATUS <br /> NUMBER OF UNITS EPA ID N: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : <br /> ++ BILLING ACKNORLEDGEMENTY 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 /> �h <br /> i <br /> r Also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JQAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws, <br /> t:.� <br /> APPLICANT'S SIGNATURE 1/C / <br /> Title: �L / Date: lG <br /> r' <br /> t.' <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 /> .y. <br /> 7 <br /> DEADLL`r2 CATES: :aspeccicn: Current / / Prior <br /> Fee Amcunt Amount Paid Date of Payment Payment Type Receipt N Click N Recvd By <br /> If IYC <br /> � c <br />