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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION ' <br /> SITE MITIGATION MASTERFILr, RECORD FORM <br /> GENERAL PROGRAM FILE.- New / Change Edit <br /> (PROGO revised 5/23/94 <br /> FACILITY ID FACILITY NAME <br /> ;i Ste hens Marine <br /> RECORD ID PRIOR DIST # <br /> s- PRIOR SWEEPS # <br /> 4- <br /> its :Miti ation / <br /> g j/ Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pi <br /> a1 eline Invest p <br /> Cher Lead Agency Site gency: WQCB DTSC EPA PL Site ater Quality Site ther Type Site <br /> �LLr i. <br /> t. DESIGNATED EMPLOYEE # / PROGRAM ELEMENT # Sv CURRENTSTATUS <br /> 9 <br /> NUMBER OF UNITS EPA ID #: '" INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> r 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 /> 4`- <br /> - APPLICANT'S SIGNATURE <br /> Title: Authorized Agent -_ Date: 05 November 1996 <br /> y 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 /> invironmental/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 isrovided to me or <br /> p my representative. <br /> •z-w,v <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> 74 <br /> x <br />