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(PROG4) revised 5/23/94 <br />DESIGNATED EMPLOYEE 4 <br />CURRENT STATUS <br /> <br />PROGRAM ELEMENT # <br /> <br />d---i SO <br /> <br />NUMBER OF TNITS : EPA ID #: INSPECTION CODE <br />Number of TANKS linked to this PROGRAM record : <br />FACILITY ID # of •90?R <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERPILE RECORD FORM <br />FACILITY NAME Ike sty,— PAI s <br />GENERAL PROGRAM FILE: New Vhange Edit <br />Pl?0 ?al/ PRIOR DIST 4 PRIOR SWEEPS * <br />RECORD ID # <br />/Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br />Other Lead Agency Site Agency: I IRWQCBI i DTSCI EPA ,II.L Sitel }dater Quality Sitel 'Other Type Site <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 /> <br />Date: <br /> <br />Title: <br /> <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 />Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 ChecAS Recvd By <br />1Z'.