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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM ?TILE: New Change Edit —}(PROG4) revised S/23/94 <br /> FACILITY ID # v U /b p FACILITY NAME l VVI C�i,1 <br /> RECORD ID # V�,`�� PRIOR DIST # PRIOR SWEEPS <br /> Site Mitigation: Environmental AssessmentST/CAP Local Hazardous Taste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQC3 DTSC EPA PL Site �ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # TPROGRAM ELEMENT # 6 CURRENT STATUS <br /> �.; <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 an <br /> the Masterfile Record Information Farm. <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 /> Z,A414 / 0)-p/Z> <br /> DEADLINE DATES: Inspection: Current / Prior <br /> Fee Amount Amount Paid Date of <br /> rr Payment Payment Type Receipt # 'heck 4 Recvd By <br />