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SAN JOAQUIN COUNrY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PRGG4) revised 5/23/94 <br /> Change—Edit_ <br /> GENERAL PROGRAM FILE: New e,, <br /> FACILITY NAME �— '' <br /> FACILITY ID # <br /> r� PPRIOR SWEEPS <br /> PRIOR DIST # # <br /> RECORD ID # <br /> al Hazardous Waste Invest <br /> zMat Pipeline Invest <br /> Mitigation: ironmental Assessmen <br /> ite Mitig ther Type Site <br /> WQCB pTSC EPA <br /> L Site <br /> ater Quality Site <br /> Agency Site envy: <br /> ther Lead Ag c7( <br /> D� <br /> # CURREIIT STATUS <br /> DESIGNATED EMPLOYEE 1:1; PROGRAM ELM' �!`� <br /> INSPECTION CODE <br /> EPA ID #: <br /> NUMBER OF UNITS : �— <br /> Number of TANKS linked to this PROGRAM record <br /> y <br /> BILLING ACKNOWLEDGof same, acknowledge that all site and/or project specific <br /> E ENT; I, the undersigned owner, operator or agent <br /> url charges associated with this facility or activity will be billed to the party identified as the BZILING PAR on <br /> pHS EHD ho Y <br /> the Masterfile Record Information Form. with all SAN <br /> I also certify that I have prepared this app <br /> lication and that the work to be performed will be done in accordance <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Date• <br /> Title: <br /> TION: in addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> authorize the release of any and all results, geotechnical data and/or <br /> AUTHORIZATION TO RELEASE INFORMATION: <br /> COUNTY pUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> the property located at the above site address hereby <br /> environmental/site assessment information tom JOAQUIN tom Or my representative. Y <br /> it is available and at the same time it is p <br /> / Prior <br /> Inspection: Current �_/.---- <br /> DEADLINE DATES: InsP Recvd By <br /> Amount Paid Date of Payment <br /> Payment Type Receipt # Cheek # <br /> Fee Amount <br /> ?moi'•°° ys <br /> it <br />