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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New <br /> /Change Edit <br /> n FACILITY NAME <br /> FACILITY ID # +� •` / OL <br /> PRIOR DIST # PRIOR SWEEPS # �4tv� <br /> RECORD ID # �2- <br /> ite Mitigation: <br /> Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> other Lead Agency SiteAgency: WQCB DTSC EPA L Site ater Quality Site ther Type Site <br /> � 31d <br /> � MI5 <br /> PROGRAM ELEMEN <br /> DESIGNATED EMPLOYCURRENT STATIIS <br /> ,NUMBER OF UNITS <br /> EPA ID #: INSPECTION CODE <br /> Number of TANYS 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-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 /> the work to be performed will be done in accordance with all SAN <br /> I also certify that I have prepared this application and that <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State,aand,Federal laws. <br /> APPLICANT'S SIGNATURE <br /> 1 Date: <br /> Title: <br /> or agent of same, of <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site assessment information to SAN <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / <br /> / Prior <br /> }'"� <br /> Fee Amount Amount Paid <br /> Date of Payment Payment Type Receipt # Check # Recvd By <br /> i5A- <br /> /,v v# <br />