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DESIGNATED EMPLOYEE # CURRENT STATUS PROGRAM ELEMENT # <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <br />Number of TANKS linked zo :his PROGRAM record <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New Change <br /> <br />Edit <br /> <br />(PROG4) revised 3/23/94 <br /> <br />FACILITY ID # D 0 I gie? 4, FACILITY NAME Alf"A, 64414.0*-tA- P412.1-4 jletil <br />RECORD ID # pp_os-..1--idner PRIOR DIST # PRIOR SWEEPS # Art4 <br />Site Mitigation, Environmental Assessment UST/CAP Local Hazardous Waste Invest 4azMat Pipeline Invest <br />Other Lead Agency Size Agency, RWQCB DTSC J <br /> <br />EPA 1 1%'PL Site <br /> <br />! i <br />Water Quality Site Other Type Site <br />BILLING ACKNOWLEDGEMENT: I-, :he 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 />DEADLINE DATES: Inspection: Current ' / Prior / / <br />Pee Amount Amount Paid Dace of Payment Payment Type Receipt # Check # Recvd 3y <br />4919V CA7714° <br />C-1C-- Z7