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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> ORIGINAL <br /> GENERAL PROGRAM FILE: New_X_ ange Edit (PROG4) revised 5/23/94 <br /> Ift <br /> FACILITY ID # FACILITY NAME <br /> -T <br /> RECORD ID # PRIOR DIST # (/�I'1•(`/ PRIOR SWEEPS # <br /> 1001-- <br /> Site Mitigation: 7�:: nvirorunental Assessment ST/CAP ocal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site ( gency: WQCB DTSC EPA PL Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # D PROGRAM ELEMENT # /'7 CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: L� 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 act' will be billed to the p ty identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared thi application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes an andards, State and Federal,, laws. <br /> APPLICANT'S SIGNA ✓✓�� -- <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 /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ?� Z3� q- 17-? <br />