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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New./Change Edit (PROW revised 5/23/94 <br /> FACILITY ID # / FACILITY NAME £ G <br /> RECORD ID # RE I PRIOR DIST k PRIOR SWEEPS # <br /> Site Mitigation: ironmental Assessment T/CAP ocal Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency SiteAgency: WQCB I DISC I I EPA I L Site I ater Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # 0/� PROGRAM ELEMENT # Zq.�T CURRENT STATUS <br /> NUMBER OF UNITS {{{VVV EPA ID #: INSPECTION CODE <br /> 3io <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-RHO 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 laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO BEI.RASE INITION: In addition to the above, when applicable, I, the owner, operator or agent o£ same, of <br /> the property located at th address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site asses ant information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and a the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Pa ant Payment Type Receipt # Check # aecvd 3y <br /> r fl/ <br /> 7-c <br />