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_ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New—X—Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # �/ 0 FACILITY NAME <br /> RECORD ID # K(ll 11��// PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: I IRWQCB DTSC EPA L Site ater Quality Site I Ither Type Site <br /> DESIGNATED EMPLOYEE # FLI(or, ) PROGRAM ELEMENT # / _ /J CURRENT STATUS r� <br /> NUMBER OF UNITS : EPA ID #: C� INSPECTION CODE C)V <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 P Mf Pe the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SIR EMN <br /> Y 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 /> AUG 21 1997 <br /> FN SAN JOAQUIN COUNTY <br /> DEADLINE DATES: Inspection: Curr.kVIRONMENjALHEALTI)DIVISION Prior <br /> Fee Amount Amount Paid Date of /Payment // Payment Type Receipt # Check # Recvd By <br /> , A y <br />