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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 XChaange Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # . {�O 0 -7 6 FACILITY NAME <br /> J rrk r[, <br /> RECORD ID # G 2-9 <br /> C q ,z PRIOR DIST # PRIOR SWEEPS # <br /> 14 <br /> ite Mitigation: n'ironcental Assessment T/CAP cal Hazardous Waste invest az at Pipeline Invest <br /> ther Lead Agency Site gency: WQCB DISC EPA L Site ater Quality Site 10 <br /> ther Type Site <br /> DESIGNATED EMPLOYEE # / S 4 I PROGRAM ELEMENT # `} �Cn CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: o\ J \J INSPECTION CODE V <br /> Number of TANKS linked to :his PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-ERD 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 Standard , S to and Federal laws. <br /> APPLICANT'S SIGN TURE <br /> Title: ate: <br /> AUTHORIZATION TO RE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property locate 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 /> ,294. 00 a9+- oa )Z -/D Dj 3o840 2 <br /> (, U * )�'9;C73 <br />