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` • JOAQUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILB RECORD FORM <br /> GENERAL PROGRAM FILE: New <br /> Change 8dit <br /> 'I (PROW revised 5/23/94 <br /> FACILITY ID $ { t L)O 77 <br /> FACILITY NAME e <br /> RECORD ID N I <br /> PRIOR DIST � PRIOR SWEEPS g <br /> its Mitigation: x vironmental Assessment ST/CAP <br /> cal Hazardous Waste Invest <br /> azMat Pipeline Invest <br /> Lt ther Lead Agency Site en <br /> cY: 1RWQCB <br /> DISC EPA L Site <br /> ater Quality Site ther <br /> Type Site <br /> PDESIG110A,T:E1').1Mp�Loy... q (� <br /> (( PROGRAM ELEMENT If CURRENT STATUS <br /> R IEPA ID p: <br /> INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned Owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-ERD 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 /> APPLICANT'S SIGNATURE <br /> Title: <br /> 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 <br /> any and ll <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES aENVIRONMENTALgHEALTHnDIVIical data and/or <br /> it is available and at the same time it is provided to me or HEALTH DIVISION as soon as <br /> my representative. <br /> DEADLINE DATES: Inspection: Current / / <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt q Check p Recvd H <br /> ?I a �� b� ��- ��q i 1 <br />