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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MA.STERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New�(�ange Edi[ (PRCG4) revised 5/23/94 <br /> FACILITY ID # I I FACILITY NAME <br /> RECORD ID # O PRIOR DIST # PRIOR S`dEEPS # <br /> Site Mitigation: Environmental Assessment ./CAP Loocal Hazardous Waste Invest —Mat Pipeline Invest <br /> ther Lead Agency Siteenv�- WQC3 <br /> DTSC EPA L Site -ter Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # O 7 PROGRAM EL�7T # �,� s� CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> ;lumber of TANKS linked to this PROGRAM record : <br /> 3I LLING 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 MAY <br /> SAN JOAQUIN CUUNTY <br /> F`UI3UC HEALTH SERVICES <br /> Title: Date: ENVIRONMENTAL HEALTH DIVISIC) <br /> AUTHORIZATION TO RELaSE INFORMATION: In addition to the above, en applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the r ase of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEA 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 Amount Paid Date of Payment Payment Tyne Receipt Check # Recvd By <br /> S. . X55 <br />