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0 <br /> 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 # ( b I q FACILITY NAME SS/'T 1�J-toll{ o r"-e Nt 61✓ <br /> RECORD ID # O` 0. ( y✓1 C`O�+l y� PRIOR DIST 4 PRIOR SWEEPS kn�1 <br /> LcWit!s< 14f-v< . <br /> Site Mitigation: iro=ental Assessment ST/CAP cal Hazardous Waste Invest I az at Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site ater Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE N 6 Z� PROGRAM ELEMENT +� 'z 9 J V CURRENT STATUS <br /> NUMBER OF UNITS 1177 EPA ID N: 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 Farm. <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 <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 4 Check 4 Recvd By <br /> o-7 1l 2 ¢ <br />