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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 4.nge Edit (PROG4) revised 5/23/94 <br /> TACILITY ID # O 1 Ck L 4 � FACILITY NAME <br /> RECORD ID # v S 2 l'?, Z 3 y PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency Sitegency: WQCB DISC L <br /> EPA L Site �Water Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # Foa(/ <br /> PROGRAM ELEMENT # Z 9-5Q CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: ` INSPECTION CODE <br /> :lumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 11, 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,Feder ws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RE E 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 # Check # Recvd By <br /> LpX't 11o4�0'1 . <br />