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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 # (0�D�33 83 FACILITY NAME ' QY <br /> RECORD TO # Y P D PRIOR DISE # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site envy: WQCH OTSC EPA Site -ter Quality Site Chez Type Site <br /> DESIGNATED EMPLOYEE # 64 U 0( PROGRAM ELEMENT # / 7 / O CURRENT' STATUS v� <br /> NUMBER OF UNITS : EPA IO #: l/ Y� 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-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 he performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> i <br /> Title: Date: <br /> AUTHORIZATIO71ocate <br /> INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the propertyhe above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> e ironmentament information to SAN JOAfQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is avail. e same time it is provided to me or my representative. <br /> Z.v U - c,0 g6-CT <br /> DEADLINE DATES: Inspection: Current / / Prior / / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Z�l. �I• 7. 5 •o i o31 � �- C.� <br />