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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New ?(.Change /' Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # ? V^ FACILITY NAME /-/�• <br /> RECORD ID # ✓ PRIOR DIST # PRIOR SWEEPS # <br /> 6t 0,51818 7 <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> --------F-T- <br /> -----P <br /> ther Lead Agency SiteAgency: �RWQCBDTSC EPA L Site ater Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE # O S PROGRAM ELEMENT # 12-7.&O CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent o that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or a i y 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 thi pplication and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and andards, 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 /> J• 'Po¢30 9 <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2� 2& z• 2`�-°Z Z o 1,7-1 <br /> /a s1°a <br />