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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECCRD FORM <br /> GENERAL PROGRAM FILE: NewjChange Edit (PROG4I revised 5/23/94 <br /> FACILITY ID # DO//31.f�� FACILITY NAME �10?�G/ <br /> RECORD ID # 0 5/7.�a PRIOR DIST # ?R!OR SWEEPS # <br /> Site Mitigation: omentalAssessme ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site envy: wQ® DISC EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # 2 Y PROGRAM ELEMENT # D 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 of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated w this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Fo <br /> I also certify that I have prepared this a lication 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, hen applicable, I, the owner, operporvor agent of same, of <br /> the property located at the above site address hereby authorize th release of any and all results, E naucil�ata and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUB C HEALTH SERVICES ENVIRO �N as soon as <br /> it is available and at the same time it is provided to me or my repre tative. OCT <br /> u 2001 <br /> ��JJ <br /> SAN JOAQUIN COUNTY <br /> OU r> 76,-5 ,�,1��ROBLIC HEALTH SERWC <br /> ISIcro <br /> DEADLINE DATES: Inspection: Current NIFIFIEHIIAlPrior <br /> Fee Amount Amount Paid Date of Payment Payment'Ty.. Receipt # Check # Recvd By <br /> (� I0/03/DI <br />