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SAN JOAQU321 COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> r <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment T/CAP Iocal Hazardous Waste Invest -Mat Pipeline Invest <br /> Other Lead Agency SiteAgency: �WQCB <br /> OTSC EPA L Site �ater Quality Site ID, <br /> her Type Site <br /> S� O1 � �1 � <br /> DESIGNATED EMPLOYEE # 0 75-/v PROGRAM ELEMENT # 01 9 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: 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 -sex— <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 arty and all results, geotechnical data and/or <br /> ezrvironmental/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 Xo 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 /> i. <br /> 3,v 393.c1l) /()v.9 a <br />