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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 I (PR//O��G4) revised 5/23/94 <br /> FACILITY ID # 1 !\ D 0 1 -7 -7 FACILITY NAPffi Vol�� µtl}y <br /> RECORD ID # �))IP////rL�"` O SO SJ•L/—/ PRIOR DIST # PRIOR SWEEPS1- <br /> [ L <br /> 2-1 '15'0 W <br /> Site Mitigation: ironmental Assessment T/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB EPA DISC L Site a[er Quality Site then 'lYpe Sice <br /> DESIGNATED EMPLOYEE # F PROGRAM ELEMENT $ Z I To I CURRENT STATUS <br /> NUMBER OF UNITS 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 /> 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 laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION 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 /> Pee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />