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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 (PROG4) revised 5/23/94 <br /> FACILITY ID # rA I.0 <br /> 6D L-7 fO FACILITY NAME Vi G To 2 T- <br /> �/+ se-Alu /� FA(zm S <br /> RECORD ID # ffff��� PRIOR DIST # 7 PRIOR SWEEPS # <br /> �I/ a l n o S 1-- r2- <br /> Site <br /> 2ite Mitigation: tzEnvironmental AssessmentST/CAP Local Hazardous Waste Invest azMat Pipeline :nest <br /> est <br /> Lead Agency SiteAgency: �WQCB DTSC EPA FPILite ater Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE # Z l PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA T_D #: iNSPECTION CODE <br /> `lumber 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 cork 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 /> DEADLINE DATES: Inspection: Current / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �2 7`l' '��-�`I 01' 677 <br />