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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change_Edit (PROG4) revised 5/23/94 <br /> ?ACILITY ID # FACILITY NAME X� <br /> PRIOR SWEEPS # <br /> RECORD ID PRIOR DIST # -T <br /> Site Mitigation: Environmental Assessment 1UST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> r <br /> Other Lead Agency Site Agency: I iRWQCB I I DTSC I EPA S�E� Quality Site I 10ther Type Site <br /> C_�J <br /> DESIGNATED EMPLOYEE # —FPRZ� ELEMENT 4 1 2- c) I CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge z:hat all site and/or projecm specific <br /> ?HS-EHD hourly charges associated with this facility or activity will be billed to the party identified as �he 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, 1, 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 HEALT14 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 Type Receipt 4 Check Recvd By <br /> -2W7, �*7 <br />