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1' 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1111 ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New e <br /> Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # If' I /I FACILITY NAME DW CJber <br /> RECORD ID # r 7 `f PRIOR DIST # 1 PRIOR SWEEPS # <br /> �ko si 3 <br /> site Mitigation: ironmental Assessment ST/CAP <br /> cal Hazardous waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site ater Quality Site her Type Site <br /> PROGRAM ELEMENT # 2✓/ 1.. 0 1 CURRENT STATUS <br /> DESIGNATED EMP1 1 :: # 1 Vl <br /> NUMBER OF UNITS <br /> 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-HHD 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 \ r� <br /> Date- V v <br /> Title: /J <br /> /Vv <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 /> J'vv. 009e-ga) <br /> DEADLINE DATES: Inspection: Currant / / Prior / / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receioc N Check # Rccvd 3y <br /> iaoa 7 " , <br />