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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM I <br /> GENERAL PROGRAM FILE: <br /> ,� New x Change Edit 5U -! �V /— `— (PROG4) revised 5/23/94 <br /> /{.� <br /> FACILITY ID # (� Q I3 FACILITY NAME <br /> ,4t- e4! SrU <br /> RECORD ID # P S I �' PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvircnmental Assessment ST/CAP local Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site 9ency: WQCB DISC EPA PL Site ater Quality Site ther Type Site <br /> J <br /> DESIGNATED EMPLOYEE # 3(e I I PROGRAM ELEMENT # a O 1 CURRENT STATUS nn T <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-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 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 <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 /> (,YW � lgo�81 <br /> DEADLINE DATES: Inspection: Current / / Prior ! __ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check q Recvd By <br /> ars �3� s- /a�i�/off ✓ 071 2� <br />