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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 �J,, Change Edit t (PROG4) revised 5/23/94 <br /> FACILITY ZD # 00 111 a! I FACILITY NAME S�( jam/';(^I !t�,�� —){J t `)r-e-f <br /> RECORD ZD # t (11 PRIOR DIST # � �-ZP4RIOR tSWEiE/P(S ## t t! l� <br /> Site Mitigation: Environmental Assessment ITSWCAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> O <br /> they Lead Agency Site Agency: IRWQCB DTSC then <br /> EPA L Site ater Quality Site type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # U CURRENT STATUS <br /> NUMBER OF UNITS E(((PA ID #: lll!!!"` t✓✓✓J INSPECTION CODEL/ �_ <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 and Standards, 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ..r <br /> 3-r- <br /> %/ ', <br />