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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OMSION <br /> SITE MITIGATION MAST-S FILE RECORD FORM <br /> GENERAL PROGRAM FILE: New__XChange Edit (PROG4) revised 5/23/94 <br /> rr^ACILITY ID # OD �j FACILITY NAME <br /> RECORD ID # /r> l J� PRIOR OISf 9 / �PRIOR SWEEPS 0 <br /> ite Mitigation: Environmental Assessment ST/CAP al Hazardous waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site Ee--DiEl <br /> DISC EPA Site �acer Quality Site ther Type Site <br /> ---i <br /> DESIGNATED EMPLOYEE # 6V`CCC/�//UUUU PROGRAM ELEMENT Z� CURB:"NT STATUS <br /> NUMBER OF UNITS SPA ?D 4: INSPECTION CODE <br /> Number of ^RANKS linked to this PROGRAM record <br /> BILLING A=OHLEDGEMENT: 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 t tified as the BILLING PARTY on <br /> the Masterfile Record Information Form- <br /> 7- also certify that I have prepared this application that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, a and Federal laws. <br /> APPLICANT'S SIGNATURE/ <br /> Title: Date- <br /> AUTHORTZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, aperator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geatechnical 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 /> LAA14- <br /> ogrs;)-�gp <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />