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. _. # 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> Change <br /> GENERAL PROGRAM FILE: New Edit M <br /> FACILITY NAME <br /> FACILITY ID # <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID <br /> al Hazardous Waste Invest <br /> zMat Pipeline Invest <br /> ite Mitigation: vironmental Assessment ST/CAP <br /> XWQCB DISC EPA L Site ater Quality Site ther Type Site <br /> ther Lead Agency Site envy: <br /> OPROGRAM ELEt4ENT Cir STATUS <br /> PNUZ,GER <br /> ED EMPLOYEE # <br /> INSPECTION CODE <br /> UNITS <br /> EPA ID #: <br /> Number of TANKS linked to this PROGRAM record <br /> I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> BILLING ACINOWLEDGEMENT: identified as the BILLING PARTY on <br /> pHS-EHD hourly charges associated with this facility or activity will be billed to the party <br /> the Masterfile Record Information Form. <br /> this application and that the worktobe performed will be done in accordance with all SAN <br /> I also certify that I have prepared <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> E INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO and all results, geotechnical data and/or <br /> the property 1 ted at the above site address hereby authorize the release of any DIVISION as soon as <br /> nt ormation to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH <br /> environme /site assessment inf <br /> provided to me or mY representative. <br /> It is available and at the same time it is <br /> / Prior <br /> DEADLINE DATES: Inspection: Current -/ <br /> nt a Receipt # Check # Recvd BY <br /> Fee Amount <br /> Amount Paid Date of Payment Payme Type <br />