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' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /!V <br /> ENVIRONMENTAL HEALTH DIVISION <br /> COPY <br /> SITE MITIGATION MASTERFILE RECORD FOAM <br /> GENERAL PROGRAM FILE: New /Change Edit (PROG4) revised 5/23/99 <br /> FACILITY ID # FACILITY NAME J L <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest 4azMat.Pipeline Invest <br /> J� ,,� ther Lead Agency Site 9ency: WQ® DISC EPA L Site Later Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # O PROGRAM ELEMENT # Z7 5 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACPMOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS.-EHD hourly charges associated withthis facility or activity will be b,�ified as the BILLING PARTY on <br /> the Masterfile Record Information Forma <br /> I also certify that.I have prepared this applic t- Date: <br /> be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar t and:F <br /> APPLICANT'S SIGNATURE <br /> i <br /> Title: <br /> AUTWRIZATION 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 /> 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Data of Payment Payment a Receipt # Check 4 Recvd By <br />