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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: 10///' New Change <br /> <br />Edit <br /> <br />oee <br /> <br />DESIGNATED EMPLOYEE # <br /> <br />PROGRAM ELEMENT # CURRENT STATUS <br /> <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <br />Number of TANKS linked to this PROGRAM record : <br />cv44 v 7A ke <br />ee/ /54 <br />ahlt ;144-s-1( <br />y4c) <br />(PROG4) revised 5/23/94 <br />FACILITY ID # tli (1) 1 I t.i) FACILITY NAME dir?),Zitens.L. 6:74.- <br />RECORD ID # <br />._ 9 '12N <br />t j 0416q PRIOR 01ST # PRIOR SWEEPS # <br />K Site Mitigation: Environmental Assessment UST/CAP <br />. <br />Local Hazardous Waste Invest iazMat Pipeline Invest <br />- <br />Other Lead Agency Site Agency: RWQCB DTSC EPA MPL Site /later Quality Site Other Type Site <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />P115-END 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 ederal laws. <br />APPLICANT'S SIGNATURE <br />Title: Date: <br />6-t-aJ24-- <br />Prit <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 # Check # Recvd By <br />390.41141 30 <br />of, a -V--Y-7 1///' 1 ki- ": - . 5 ? V/