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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_)LEdit (PROG4) revised 5/23/94 <br /> FACILITY ID # /8 ^ ' / FACILITY NAME <br /> RECORD ID # t 1\ O,(-,c2 Xe L6 y PRIOR DIST # PRIOR SWEEPS # <br /> ice Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat.Pipeline Invest <br /> Cher Lead Agency Sitegency: WQCE DTSC EPA L Site aver Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # O/j� PROGRAM ELEMENT # �i 5/ CURRENT STATUS <br /> NUMBER OF UNITS 111�� EPA ID q: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 cc 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 RELEA/ave <br /> n addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assn to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and atis provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paiid/ Dace of Payment Payment Type Receipt # Check # Recvd By <br />