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SAN JOAQUIN COUNTY PUBLIC HEALTH S'cRVIGS <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFIL^c RECORD FORM <br /> GENERAL PROGRAM FILE: h New /�-CChange Edit (PROG4( revised 5/27/94 <br /> FACILITY ID # /•/O v D i{ 3 (� FACILITY NAME <br /> RECORD ID # • PRIOR DIST # F•YT' Y(�yG PRIOR„SWEEPS ✓t�J <br /> Site Mitigation: vironmental Ass smenc ST/CAP cal Hazardous Waste inves[ zMat Pipeline Invest <br /> then Lead Agency site envy: WQCB DISC EPA PL Site ater Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEFIP`i1'f # "/ U CURRENT STATUS A <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 of same, acknowledge that all site and/or project specific <br /> PHS-ESB) 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 /> c� <br /> APPLICANT'S SIGNATURE n� <br /> \ ^ <br /> Title: \�N// Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: I di t' to thelabdve, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above a ddress authorize t e release of any and all results, geotechnical data and/or <br /> environmental/site assessment fo t' n JOAQUIN CO LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIOP7 as soon as <br /> it is available and ae t same time t is provided to representative. <br /> DEADLINE OATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receint # Check # Recvd By <br /> ZOO Z� l 2 !001 /J�/ <br /> �► i <br />