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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 Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat,PEpel they Lead Agency Site gency: WQCB DTSC EPA L Site Ater Quality Site <br /> /31b <br /> SC .- 3/2 <br /> DESIGNATED EMPLOYEE # r J PROGRAM ELEMENT # vgsO CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> i <br /> i <br /> BILLING ACKNOWLEDGEMENT: 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 BILLING PARTY on <br /> the Masterfile Record Information Form. . <br /> I also certify that.l 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 /> I <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 /> th, 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 /> j Fee Amount Amount Paid Date of Payment Payment TYp Receipt ,# Check # Recvd By <br /> 2 <br /> 241 0 Z a <br /> FIL +� � <br />