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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 q \ 11 1 FACILITY NAME Z4� <br /> RECORD IO q yJ C '7 I PRIOR DIST q PRIOR SWEEPS q <br /> ite Mitigation: nvironmental Assessment ST/CAP cal Hazardous waste Invest zMat Pipeline Invest <br /> then Lead Agency Site gency: WQCH DISC EPA L Site ater Quality Site I 10ther Type Site <br /> /3/0 <br /> SG:�3i5 <br /> DESIGNATED EMPLOYEE q O 6 PROGRAM ELEMENT q Z7 SD CURRENT STATUS <br /> NUMBER OF UNITS EPA ID q: 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 /> ENS i-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 and that the w o omill be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and,Fede aws. <br /> i <br /> APPLICANT'S SIGNATURE /M <br /> TiCle: • 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 aReceipt # Check q Recvd By <br /> 29 fz� �i �S fi -501-6 <br />