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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 # \ Ob 1 8lon 5 FACILITY NAME <br /> RECORD ID # ` �I VG C , PRIOR DIST 4 ��,��' CCC•••,_w^� PRIOR SWEEPS # ,L <br /> Site Mitigation: X nvironmental Assessment S CAP Cal Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site ( _ envy: HOCH DISC EPA ITPL Site Water Quality Site ther Type Site <br /> i TT <br /> DESIGNATED EMPLOYEE # p 6 PROGRAM ELEMENT # 2��Sv CURRENT STATUS <br /> NUMEER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, St a and;Federal laws. <br /> I <br /> APPLICANT'S SIGNATURE <br /> I <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 /> 9'0 2oa8 2$5 Cr-�t <br />