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y ` <br /> (J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^ V <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> VJ <br /> b A r s � � <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # g�Cf'� FACILITY NAME / i_ <br /> !!�% [ l'• <br /> RECORD ID # x ( PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP ocal Hazardous Waste Invesc azMat Pipeline Invest <br /> other Lead Agency SiteAgency: �WQCB DTSC EPA L Site Inater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # 0( CURRENT STATUS <br /> Il <br /> 1 <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 /> ?HS-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 /> 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 /> o os 3 3 =-a' <br /> DEADLINE DATES: Inspection: Current / 1 Prior -/-/ <br /> Fee Amount Amount Paid Date of ?ayment Payment Type Receipt # Check # Recvd By <br /> - 4023 <br /> J s <br />