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"rA <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New <br /> Change Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # 9L <br /> !/v FACILITY NAME <br /> RECORD ID # /5�f 1I/I PRIOR DIST # <br /> PRIOR SWEEPS # <br /> ite Mitigation: nvironmental Assessment T/CAP <br /> ocal Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site gency: WQCB DTSC <br /> EPA PL Site Ater Quality Sit- ther Type Site <br /> rof <br /> OYEE # / ,� PROGRAM ELEMENT # <br /> v TZ=CURREWNT STATUS <br /> EPA ID #: <br /> INSPECTION CODE <br /> linked to this PROGRAM record <br /> BILLINGACKNOWLEDGEMENT: 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 BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I ave prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance odes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addx 'on to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address he by authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JO UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to a or my representative. <br /> DEADLINE DATES: Inspection: current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check 4 Recvd By <br />