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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> 'i <br /> GENERAL PROGRAM FILE: New__)_� Change Edit (PROG4) revised 5/23/94 <br /> s <br /> FACILITY ID # Dzr ��� FACILITY NAME <br /> RECORD ID # �—(� �] J PRIOR DIST # k� I PRIOR SWEEPS # <br /> E ' <br /> ' a <br /> ite Mitigation: U 1 C Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> 1 <br /> they Lead Agency Site Agency WQCB DTSC EPA L Site .� ater Quality Site they Type Site <br /> PROGRAM ELEMENT # CURRENT STATUS <br /> DESIGNATED EMPLOYEE # �rn� 3' 0 ;I <br /> F vj <br /> VUMBER OF UNITS EPA ID #: 11INSPECTION CODE <br /> Nkimber of TANKS linked to this PROGRAM record I <br /> it <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same.: acknow ledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to th'e 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 ner£ormei will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws_ <br /> APPLICANT'S SIGNATURE <br /> i <br /> Title- Date: I <br /> i <br /> i <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1. :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:S£RVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> itis available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current 1 / Prior <br /> ' !I <br /> i <br /> 'Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />