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• <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> X S� <br /> GENERAL PROGRAM FILE: New ! Change Edit ( { ROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # "Ob �1a'�(�-`\ PRIOR DIST # W PRIOR SWEEPS # <br /> site Mitigation: Gnvironmencal Assessment ST/CAP cal Hazardous waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site [gency: IRW()CB <br /> DISC EPA <br /> �Site aQuality Site71-her Type Site <br /> DESIGNATED EMPLOYEE # � I PROGRAM ELEMENT # a ! s CURRENT STATUS <br /> :LUMBER OF UNIT'S EPA ID #: ! INSPECTION CODE 366 <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT. 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PRS-8M 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 z?MIRQNMENi'AL 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 /> 3 �3 10 10 a ✓ J 3�.�5 �,.1� <br />