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SAN JOAQUIN, COUNTY PUBLIC HEALTH SERVIr <br /> ZNVIRONMENTAL HEALTH DIVISION. <br /> SIT MITIGATION MASTERFILE RECORD FORM <br /> / (pROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: <br /> New Change Edit____ <br /> -eACILITY ID # rA FACILITY NAME ✓( J� S <br /> r���� PRIOR DIST # <br /> PRIOR SWEEPS # <br /> RECORD ID # 3 <br /> Elher <br /> ation: `� zvironmental assessment ST/CAP <br /> ocal Hazardous Waste Invest azMat Pipeline invest <br /> DISC <br /> EPA L Site ater Quality Site then 'Type Site <br /> Agency Site gency: <br /> ogOGRAM ELEMENT # CURR&.rr STATUS <br /> P�,Jjj.'MER <br /> GNATED EMPLOYEE # <br /> INSPECTION CODE <br /> OF UNITS ____— <br /> EPA ID #: <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 Informal-en Form. <br /> I also certify that I have prepared this app <br /> 1-cation 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 /> Date: <br /> Title: <br /> In ad&tion to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEASE INFORMATION: all results, geotechnical data and/or <br /> the property located at the above site address hereby <br /> authorize the release of any and <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 /> / / <br /> Prior <br /> DEADLINE DATES: Inspection: Current <br /> Date of Payment Payment Type Receipt # Check # Recvd By <br /> Fee Amount Amount Paid <br />