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0 . 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New /Change Edit (PROG4) revised S/23/94 <br /> FACILITY ID # rA a 0(-1 O"1 FACILITY NAME <br /> RECORD ID # ��1 ffff'LLLG�V�� O�d� PRIOR DIST $ PPRRIOR SWEEPS # <br /> Site Mitigation: vironmental Assessment ST/CAP cal Hazardous Waste Invest ZMat Pipeline Invest <br /> Other Lead Agency Site 9ency: I JWQCB DISC EPA L Site ater Quality Site ther Type Site <br /> ,3ro <br /> DESIGNATED EMPLOYEE # b PROGRAM ELEMENT # �� 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 <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition Co 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 /> 3oRq C� <br /> 2r 7//��0� <br />