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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MAS'TERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New 4 <br /> Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD 1D # 50 q ZD PRIOR DIST # PRIOR 4zps # <br /> ite Mitigation: Ermitoomlental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Siteency: WQCB DTSC EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # / )/^X PROGRAM ELEMENT # "C-�j i s� CURRENT STATUS <br /> NUMBER OF UNITS (/V/ LLLJJJ EPA ID #: 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 /> PRS-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 c the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNT! Ordinance Codes and Standards, Sta and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TOE 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 Date of Payment Payment Type Receipt # Check # Recvd By <br />