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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 S/23/94 <br /> FACILITY ID # FACILITY NAME �l/11LP <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: nvironmental Assessment /GAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site <br /> �gn-y��W DTSC PA PL Site atez Quality Site Fther Type Site <br /> %w <br /> 6'. <br /> DESIGNATED EMPLOYEE # C d 0 PROGRAM ELEMENT # 5o CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: ���iii ��I INSPECTION CODE <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 ItTIO addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> r <br /> the property locat d at the ov 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 /> i <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 # Check # Recvd By <br /> 2323' 9 /23 /9 C 225Y <br />