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SAN JOAQUIN COUNTY PUBLIC HEkLTH SERVICES <br /> ENVIRONMENTAL HEALTH ❑ VISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE; New 1/ Change Edit 2�+ i `rJ (PROG4) revised 5/23/94 <br /> FACILITY ID # Y !!N��;P 733 7 FACILITY NAME <br /> RECORD ID # Ae(/J e6 16)16 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ✓ Environmental Assessment ST/CAP bocal Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency Site envy: WQCS I I DTSC I EPA I kL Site I -ter Quality Site Tther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # ` S��>, 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 f same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will 3e 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. <br /> APPLICANT'S SIGNATURE H1 Hopes Venture, Gen.Partnershi <br /> Title: Managing partner Date 7/30/96 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when Ipplicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the re ease 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 repres mtative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> I <br /> rr f <br />