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t: <br /> SAN SOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION - - - <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> / (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New V Change Edit <br /> FACILITY ID M /( OO I ��. "� e^ACILIT_' NAME 1n D m <br /> RECORD ID 4 I � �a�' PRIOR DIST 9 ''IM„ PRIOR SWEEPS <br /> Site Mitigation: Environmental AssessEST/CAP cal Hazardous Waste Invest azMat Pipeline invest <br /> Cher Lead Agency Site gency: WQ® EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE k <br /> PROGRAM ELEMENT N �9, CURRECff STANS <br /> FUN®ER OF UNITS : <br /> EPA ID R: 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 /> PPS-EHD hourly charges associated with this facility or activity will be billed to the party idencf ed as the BILLING PARTY an <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 inzormation to SAN SOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> m <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 s <br /> of Payment Payment Type Receipt 4 Check 4 Recvd By <br />