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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Chan/ge <br /> Edit <br /> FACILITY ID # G FACILITY NAME D2 <br /> RECORD ID # /�/GGGG PRIOR DIST # PRIOR SWEEPS # <br /> 5� �d2bS <br /> ite Mitigation: ironmental Assessment ST/CAP <br /> cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site gency: WQCB DISC EPA L Site at Quality SiteO <br /> then Type Site <br /> DESIGNATED EMPLOYEE # U 6 PROGRAM ELEMENT # �9�O CURRENT STATUS <br /> NUMBER OF UNITS <br /> EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 0 I In addition t�above, when applicable, I, the owner, operator or agent of same, of <br /> the property located a the site address hereby authoease of any and all results, geotechnical data and/or <br /> environmental/site a exam _ information to SAN JOAQUIN OUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available an at the same time it is provided to me C.H.r my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 6 . Z67� <br /> i <br />