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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFIL'a RECORD FORM <br /> N New�C!aige Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE <br /> FACILITY ID # FACILITY NAME tjo f '1A TV <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> /v ot° L-1 <br /> site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest I A—Mat Pipeline Invest <br /> Other Lead Agency SiteAgency: �WQCB DISC L <br /> EPA L Site ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # Z` PROGRAM ELEMENT # 1 C`�O CURRENT STATUS <br /> NUMBER OF UNITS 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-EHM 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 perfo-ped will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State nd Federal laws. <br /> APPLICANT'S SIGNATURE : <br /> Title: , Date: /G/+(O–� <br /> =13CRIZATION TO RELEASE INFORMATION: In addition to the:above, when applicable, 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 ?-MALTA 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 /> C)C, o Lo <br />