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1 • <br /> r - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New V Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # F11. �J PACTLITY NAME <br /> RECORD ID # I PF V52 3 J16-6 7l CJ`7 PRIOR DIST # vv PRIOR SWEEPS # <br /> Site Mitigation: vironmental Assessment ST/CAP al Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSCEPA L Site [later Quality Site I 10ther Type Site <br /> Q Irc/C'' <br /> DESIGNATED EMPLOYEE # D/ PROGRAM ELEMENT # Z/ %9? 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 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 /> 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 in available and at the same time it is provided to me or my representative. <br /> �n,vvra7c� � a <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd 9v <br /> 701 2;q`( 7 <br />