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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MAS'IERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # Fig FACILITY NAME �l`a,(Q , PCA(1Q4 5 eAX11 c� <br /> RECORD ID # 17 <br /> / �7 PRIOR DIST # PRIOR SWEEPS # <br /> CQ / <br /> Site Mitigation: ironmental Assessment T/CAP al Hazardous Waste Invest a Mat Pipeline Invent <br /> Other Lead Agency Site envy: NOCE DTSC EPA L Site ater Quality Site ther Type Site <br /> C3(0) <br /> DESIGNATED EMPLOYEE # / Z G PRQGRAM ELEMENT # a, I 70-TL <br /> �AT� <br /> NUMBER OF UNITS : 'O TEPA 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-END 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 /> sovironmental/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 /> W4 I D 95x'7 <br /> DEADLINE DATES: Inspection: current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt k Check # Recvd By <br />