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f <br /> SAN JOAQUIN CDUWTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New <br /> Ohange Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID p <br /> EEEEENit <br /> RECORD ID p <br /> PRIOR SWEEPS it <br /> Itaij <br /> ssment /CAP <br /> cat Hazardous waste Snvest <br /> azMat Pipeline Invest <br /> DTEc EPA L Site <br /> acez Quality Site the_ <br /> ' Type Site <br /> k <br /> rNumber <br /> EMPLOYEE # PROGRAM ELEMEtiT R 9 <br /> Z[ 5Q CURRENT STATUS <br /> UNITS EPA ID p: <br /> INSPECTION CODE <br /> 3 <br /> NKS linked to this PROGRAM record <br /> i <br /> t <br /> Y <br /> lBILLING 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 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: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: <br /> In addition to the above, when applicable, I, <br /> the property located at the the owner, operator or agent of same, of <br /> 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 <br /> —/— / Prior <br /> Fee Amount Amount Paid <br /> Date of Payment Payment Type Receipt p Check p <br /> Recvd By <br /> Z__1 , 23 I �� �ba�o�oo <br />