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.i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3 <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> 3 <br /> GENERAL PROGRAM FILE: New V/ Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PIPRIOR DIST # PRIOR SWEEPS # <br /> ,I <br /> ite Mitigation: nvironmental Assessment T/CAP 1,0cal Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency Site ency: WQCB DTSC EPA L Site ater Quality Site then Type Site <br /> 3 <br /> DESIGNATED EMPLOYEE # O PROGRAM ELEMENT # CDRR <br /> �G�C ENT STATUS <br /> MEN <br /> NUMBER OF UNITS EPA ID #: I J 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-EHD hourly charges associated with this facility or activity will he 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: Date.- <br /> AUTHORIZATION <br /> ate: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 /> 3 <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />