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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> Edit (PROG4) revised S/23/94 <br /> GENERAL PROG§t ,M FILE: New Change _ <br /> FACILITY ID # FACILITY NAME <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # <br /> Site Mitigation: vironmentalEAssesEsment jHazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency Site gency: EPA ite ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # <br /> P=ROGRAM CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: f/ 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 chat 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 /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE INF TION: In addition to the above, when applicable, I, the owner, operator or agent of same, Of <br /> any and all results, geotechnical data and/or <br /> the property located at a above site address hereby authorize the release of <br /> COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site as ssment information to SAN JOAQUIN <br /> it is availabl at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / <br /> / Prior / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # <br /> Recvd By <br />