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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 Change Edit <br /> (PROG9) revised 5/ 3/94 <br /> FACILITY ID # DO l 0 D 0 FACILITY NAME �0 U �'/ fI <br /> Opt <br /> RECORD ID # AF 5�O PRIOR DIST # PRIOR SWEE # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site gency: �RWQCS DISC EPA L Site -ter Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # LO-6 <br /> 6 P Lj PROGRAM ELEMENT # �j0 CURRENT STATUS <br /> NUMBER OF UNITS : EP///A 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 be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE1 •/ MEWED <br /> DEC 2 6 1997 <br /> Title: DateENVIRONMENTAL HEALTH <br /> : <br /> PERMIT/SERVICES <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 Paym nt Payment Type Receipt # Check # Recvd By <br />