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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> Edit <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: NewChange_ <br /> FACILITY ID # r1 Q! rn FACILITY NAME K�tL <br /> 1 J D 102f PRIOR DIST # PRIOR SWEEPS <br /> RECORD ID # ?�(C 4 <br /> y nvironmental Assessment ST/CAP ocal Hazardous Waste Invest azMat Pipeline invest <br /> E <br /> igation:ead Agency Site gency: WQCB DTSC EPA L Site �7ater Quality Site Cher Type Site <br /> PROGRAM <br /> DES I:GNA:TE:DE::E,[_ ELEMENT # �/� CURRENT STATUS <br /> GNATED EMPLOYEE # V <br /> NUMBER OF UNITS : <br /> EPA ID #: INSPECTION CODE : <br /> ;lumber 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 /> ity or activity will be billed to the party identified as the BILLING PART`_' on <br /> PHS-EHD hourly charges associated with this =acil <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 /> Date: <br /> Title: <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 /> Fee Amount Amount ?aid Date of <br /> Payment Payment Type receipt # Check 4 Re By <br />