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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 /> vrvwN P��11��c 2.4ic¢oPsn <br /> FACILITY ZD # C) 4 C�" FACILITY NAME Ada f-GvW CNT <br /> RECORD ID # S�l( q-7 PRIOR DIST # PRIOR SWEEPS # <br /> S T2 E E 7- <br /> L <br /> ite Mitigation: vironmental Assessment ST/CAP cal Hazardous Waste invest �azMat Pipeline Invest <br /> O <br /> ther Lead Agency Site gency: IRWQC13 DTSC EPA L Site � - <br /> ater Quality Site Ther Type Site <br /> DESIGNATED EMPLOYEE # / Z 1 \ PROGRAM ELEMENT # sq I CURRENT STATUS <br /> NUMBER OF UNITS ,O EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record 3 / 0 <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 chat I have prepared this application and chat 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Tvpe ;�edeipc # Check # Recvd By <br />