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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRCNMENTAL 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 # 0O 75-49 <br /> ?AGILITY NAME <br /> RECORD ID # <br /> cRIOR DIST # PRIOA SWEEPS q <br /> its Mitigation: <br /> nvironmental Assessment ST/CAP <br /> ocal Hazardous Waste Invest <br /> azMat Pipeline Invest <br /> then Lead Agency Site <br /> ency; WQCB DISC ter Quality Site they <br /> Type Site <br /> [N.UMBER <br /> nTANXS <br /> o C I PROGRAM ELEMENT & <br /> J 2�,J LJ CURRENT STATUS <br /> EPA IDINSPECTION CODE this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT; 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 the Party identified as the BILLING P <br /> the Masterfile Record Information Form. ARTY on <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 <br /> /alaws. <br /> APPLICANT'S SIGNATURE <br /> Title: O /V Date:_ <br /> 81997 <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 /> environs tal/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENT�'AI, III <br /> it is available and at the same time it is provided to me or my representative. <br /> �NVIi�,jW�ba.V1SIO1q-ss'soon as <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Paymenta Receipt p <br /> �'P P Check $ Recd 8y <br />