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I <br /> S <br /> SAN JOAQUIN COUNTY PUBLIC HEA�LTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE �9CORD FORM <br /> GENERAL PROGRAM FILE: NewxCChange Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # ACIL1Ty NAME 4K I — K b Gfv CAP— �f A S J J <br /> RECORD ID # 01 <br /> PRIOR DIST # PRIOR SWEEPS # J <br /> Site Mitigation: Environmental Assessment T/_CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site AgencyTFwoCB1 <br /> D £PA L Site Later Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # �/ ELEMENT # y 5-0CURRENT STATUS <br /> NUMBER OF UNITS 6 L!U PROGRAM <br /> EPA ID #: 4_ INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent c1f same, acknowle a that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will }fie billed to a party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and t t the w rk:toi e p rfo ed will be don ;Fi accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and F eral�aw <br /> APPLICANT'S SIGNATURE <br /> I <br /> r <br /> Title: Datei <br /> AUTHORIZATION TO RELEA>rNTION: In addition to the above, when 4pplicable, I, the owner, operator or agent of same, of <br /> the property located aove site address hereby authorize the re4ease of any and all results, geotechnical data and/or <br /> environmental/site assinformation 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 ray represintative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment.Type Receipt # Check # Recvd By <br /> 42� `� 3� �� l �� <br />