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JK <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITS MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: ,,/New T Change Edit (PROG4) revised 5/23/94 <br /> OyFACILITY ID # / 7 to 7 FACILITY NAME 7 9 3 <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> site Mitigation: nvironmental Assessment k <br /> T/CAP ocal Hazardous Waste Invest —Mat Pipeline Invest <br /> Other Lead Agency Site envy: WQCB DTSC EPA L Site ater Quality Site I 10ther Type Site <br /> 6187 <br /> DESIGNATED EMPLOYEE C, PROGRAM ELEMENT # CURRENT STAINS <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-ECB) 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 performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. R§11 L <br /> E I VED <br /> APPLICANT'S SIGNATURE <br /> ENVIRONMENTAL HEALTH <br /> Title: Date: MIT/SERVICES <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: Curren _/_/- Prior <br /> Fee AmounC Amount Paid Date of Payment Payment Type Receipt # Check # Recvd Sy <br /> g (ly/93 <br />