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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION D y <br /> SITE MITIGATION MASTERFILE RECORD FORM � 1/ <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID py IqAiLe I <br /> FACILITY NAME <br /> RECORD ID # PR 0 6 <br /> 2 1' PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: vironmental Assessment ST/CAP 1 Hazardous Waste Invest —Kat Pipeline Invest <br /> Cher Lead Agency Site envy: WQ® DISC EPA L Site -ter Quality Site then Type Site <br /> DESIGNATID EMPLOYEE # I 10 <br /> PROGRAM ELEMENT # /,9 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: O INSPECTION CODE <br /> vlL31l� <br /> Number of TANKS 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 an/d SS1tanda1rds, State and Federal laws. <br /> APPLICANT'S SIGNATURE Gln /l'�� <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 Da Ce o£ Payment Payment Type Receipt # Check # Recvd 3y <br /> Y6� o1 )-f °- ZaZ'1 b7 �� �«SS 1 � <br />