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SAN 70AQUIN COUNCY PJBLIC HEALTH SEPV3CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New 7- Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # _' 77--- FACILITY NAME S �j�*�Q� 11_ <br /> i <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # v ✓ <br /> to Mi igation; nvironmental AssessmentUST/CAP ocal Hazardous Waste Invest azMat Pipeline Invest <br /> S[, ther Lead Agency Site gency: '<4WQCHI i DTSC EPA PL Site ater Quality Site Fher Type Site <br /> DESIGNATED EMPLOYEE PROGRAM ELEMENT #T <br /> �� CURRENT 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, 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 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 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount I Amount Paid Date of Payment Payment Type Receipt # check # i Recvd By <br />