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SAN JOAQUIN COMM PUBLIC HEALTH SERVICES PINK. <br /> ENVIRONMENT HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG9) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New <br /> Change�Edit_� <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: ironmental Assessmen / <br /> L Site <br /> ater Quality Site Cher Type Site <br /> ther Lead Agency Site envy: WQCB DTSC EPA <br /> DESIGNATED EMPLOYEE # <br /> DY/ PROGRAM ELEK # f� r�C.J =C=MUMZENnT <br /> INSPECTION CODE <br /> NUMBER OF UNITS <br /> EPA ID #: <br /> Number of TANKS linked to this PROGRAM record <br /> o erator or agent of same, acknowledge that all site and/or project specific <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, p <br /> with this facility or activity will be billed to the party identified as the BILLING PAR on <br /> pME_EHD hourly charges associated <br /> the Masterfile Record Information Form. <br /> I also certify that Z have prepared this application and that the work 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 /> Date: <br /> Title: <br /> INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEASEgeotechnical data and/or <br /> the property located at the above site address hereby authorize the release of any and all results, HEALTH DIVISION as soon as <br /> environmental/site assessment information to SAN JOAQUZN COUNTY PUBLIC HEALTH ��� ENVIRONMENTAL <br /> it is available and at the same time it is provided to me or my representative. <br /> Prior <br /> DEADLINE DATES: Inspection: Current <br /> Payment Type Receipt # Check # Recvd BY <br /> Fee Amount Amount Paid .Date of Payment / <br /> u, o• t'5 Z4�10 <br />