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4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> 3 3 <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # v l t FACILITY NAME � ���f/ v�"5f4 4 f (' //� p <br /> RECORD _TD # `J� PRIOR DIST # � �PRCIOR SWEYEP,S`h# [ j JTJ <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous haste Invest �azMat Pipeline invest <br /> Other Lead Agency SiteAgency: WQCB DTSC EPA L SiteI-Ter Quality Site ther Type Sire <br /> DESIGNATED EMPLOYEE #T,-?, <br /> 3 PROGRAM ELEMENT # S CURRENT STATUS <br /> NUMBER OF UNITS EPA T_D #: INSPECTION CODE 3 a <br /> Number of TANKS linked to chis PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: , 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 chat I have prepared this application and that the work to be performed will be done _'m accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> 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 Receiot <br /> Check 4 Recvd By <br />