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SAN JOAQUIN COW,TY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION :MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change EdiC 5/23/99 <br /> ;PROG4) revised <br /> FACILITY ID d ///�� 606 9 FACILITY <br /> RECORD ID k \ -j/ o O O l I PRIOR DIST # FRIOR SWEEPS 4 <br /> ice Mitigation: nvironmental Assessment ST/CAPocal Hazardous blasts _invest azMat Pipeline Invest <br /> ther Lead Agency Site ency: WQCB DISC EFA PL Sice acer Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # / FROGRAM ELEMENT CVRAENI STATUS <br /> NUMBER OF UNITS. : / EPA ID k: <br /> INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: _, the undersigned owner, operator or agent of same, acknowledge chat all site and/or project specific <br /> PHS-c'HD hourly charges associated with ;his 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 1 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 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 Amount Amount Paid Date of Payment Payment 'Type ±qeCei1EPt # ECheck Recvd By <br /> 3q� TYom- 1'2, of rX- z- <br />