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.i <br /> ss '� <br /> " _ _ Y <br /> SAN JOAQUIN roU'Y PUBLIC HF,�ILTH SERVICES <br /> ENVIRONMENTAL HEALTH nrvISION j4 <br /> T SITE MITIGATION MASTERFILE RECORD FORM <br /> v; <br /> GENERAL PROGRAM FILE: <br /> -_Edit <br /> (PR <br /> b OG4i revised 5/23/94 <br /> FACILITY ID # ! <br /> 7S�� FACILITY NAME <br /> RECORD ID # �A 0 l C <br /> DIST # t�. � -- � <br /> PRIOR SWEEPS <br /> - <br /> I <br /> ite Mitigation: ironmental Assessment !.,I <br /> /CAP 1 hazardous waste Invest <br /> they Lead <br /> ZMat Pipeline Invest <br /> Agency Site envy: WQCH � ! <br /> DTSC EPA L Site ater + <br /> Quality Site ther Type Site <br /> d. <br /> ...............................I............... ................ <br /> DESIGNATED # <br /> o� y PROGRAM ELEMENP # 747. so Ci1,tRENT STATUS <br /> NUMBER OF UNITSy i3 <br /> EPA ID INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACMOWLEDGEMENT: I, 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 k <br /> the Masterfile Record Information Form. sfi i i <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 /> 11 <br /> APPLICANT'S SIGNATURE <br /> Title: QN E' 1`�r Avim Date: <br /> AUTHORIZATION To RELEASE INFORMATION: In addition to the above, when applicable, I, the'llowner, <br /> ooyEaMent of same, of f <br /> the property located at the above site address hereby authorize the release of any and all resulEbr§eotcchnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRO HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> MrI 8 1997 <br /> sArLirN COUNTY. <br /> PUSUC HEAL <br /> ENVfRONMENTgL HEALTH niwsie,, i <br /> DEADLINE DATES: Inspection: Current / / Prior; <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Re j <br /> Z3Z317-17 ✓ Dq�b� ' <br /> � � -..x.. .wY'.xr;-'r.• - x.. � .. � _.h.-:, � � ,,•�.r_. ,ter,-- -"y <br />