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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICeS <br /> E,4VIRONMENTAL HEALTH DIVISION <br /> - <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change <br /> Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # D D 1 Sa a FACILITY! NAME ( 3 J ly <br /> RECORD ID # Sa a O S� PRIOR DIST # ?RIOR SWEEPS <br /> Site Mitigation: vironmental Assessment ST/CAP caaqazardou—s aste Invest azMat Pipeline investther Lead Agency Site gency: DTSC EPA ate- Quality Site the- Type Site <br /> G PROGRAM ELEMIII T # I 0 CURRENT STATUS <br /> DESIGNATED EMPLOYEE # ( l <br /> Iv'in48ER OF UNITS <br /> EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to phis PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity Will be billed to the party identified as the SIT–LING PARTY on <br /> the Masterfile Record Informacicn 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 I=- –,rl 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 Date of Payment Payment Type Receipt # Cseck # Recvd By <br /> a d z� r� � <br />