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'x <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New�Change Edit PR <br /> ( OG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ironmental Assessment /CAP Local Hazardous Waste Inv( x est azMat Pipeline Invest <br /> Other Lead Agency Site envy: WQC9 DTSC EPA Fit- ater Quality Site Cher Type Site <br /> DESIGNATEDEMPLOYEE # / y TpRoGRAm <br /> EL'MENT CURRENT STATUS <br /> NUMBER OF UNITS : {(/ U EPA ID #: b INSPECTION CODE <br /> Number of TANKS linked to 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 PARTY on <br /> the Masterfile Record Information Form. <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 /> /�J <br /> APPLICANT'S SIGNATURE ; <br /> Title: Date- <br /> AUTHORIZAT'IO 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 /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTA DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> 7 <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> L / <br /> ta�v <br />