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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 # L! 00 l'wa g FACILITY NAME <br /> RECORD ID I5 PRIOR DIST # / 'iP'RvIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �zMat Pipeline Invest <br /> Other Lead Agency Site ency: WQCB DTSC EPA L Site �ater Quality Site I Cher Type Site <br /> DESIGNATED EMPLOYEE # � PROGRAM ELEMENT # 7 �� C[7RRENT STATUS <br /> NUMBER OF UNITS EPA ID #: _ INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, ackrcwledge 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 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 /> !J <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE TION: In addition to the above, when applicable, I. the owner, operator or agent of same, of <br /> the property located at above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site ass sment 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 /> 9V3 y/ <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receiot # Check # Recvd By <br /> 2, 31 q 6czz:` <br />