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0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New <br /> Change Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # p ( S./n FACILITY NAME <br /> RECORD ID # 5 ( (� S S PRIOR DIST p <br /> PRIOR SWEEPS # <br /> its Mitigation: ironmental <br /> Assessment ST/CAP cal Hazardous Waste Invest <br /> azMat Pipeline Invest <br /> they Lead Agency Site <br /> gency: WQCS DISC EPA L Site atez <br /> Quality Site ther Type Site <br /> ffDESIGNATEU # PROGRAM ELEMENT # �` CURRENT STANS <br /> EPA ID #: <br /> INSPECTION CODE <br /> d to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, Operator or agent Of same, acknowledge that all site and/or <br /> proj <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLINGCPARTY lonc <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: <br /> 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 /> envizonmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL REALTH 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 / / <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Pa ent <br /> ym Type Receipt # Check # Recvd By <br /> �CS'S-odrz)2 s` (Z— -2 f kA � <br />