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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New- Changs Edit <br /> (PROG4) revised g/23/94 <br /> FACILITY ID k rA ENE]FACILITY NAMERECORD ID k PRIOR DIST k fill PRIOR SWEE S k <br /> ite Mitigation: x ironmental Assessment ST/CAP cal Hazardous Waste Invest <br /> zMa[ Pipeline Invest <br /> Ll Cher Lead Agency Site gency: WQCB DTSC EPA L Site ater <br /> Quality Site Cher Type Site <br /> EDESIGNIATED k � PROGRAM ELEMENL k CURRENTSTATUS <br /> EPA ID k: INSPECTION CODE <br /> ed to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/ project specific <br /> PHS-END 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: 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 Amounc Amount Paid Date of Payment Payment Type Receipt K Check k Recvd 8 <br /> Y <br /> ?/Z-7/67 < « X35`► l�/� <br />