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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> X Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change <br /> FACILITY NAME U 5/. <br /> Ep,ECORDID <br /> PRIOR DIST # PR SWEEPS # <br /> Yal Hazardous Waste Invest zMat Pipeline Invest <br /> Ether <br /> itigation: f\� vizonmental Assessment T/CAP <br /> Lead Agency Site envy: <br /> WQCB DTSC EPA L Site ater Quality Site ther Type Site <br /> O PROGRAM CIIRR�7T STATUS <br /> DESIGNATED EMPLOYEE # ((may <br /> INSPECTION CODE <br /> NUMBER OF UNITS EPA ID #: <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 chat I have prepared this application and that the work to be performed will be done ii accordance with all SAN <br /> JOAQUIN COUNTY ordinance Codes and Standards, State and Federal laws. <br /> s 1 <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> IN-FORMA •TIONIn addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO y geotechnical data and/or <br /> the property locac at the above site address hereby authorize P�UBLZClea�se�f�an�� a1��reOsu�=�g�,r•� DIVISION as soon as <br /> environmental/s' a assessment information to SAN JOAQUIN COUNTY <br /> it is available and at the same time it is provided to me or my representative. <br /> / Prior <br /> DEADLINE DATES: Inspection: Current / <br /> Ym Receipt # Check # Recvd By <br /> Fee Amount Amount Paid Date of Payment Payment Type p <br /> . , ,L Z3 o <br /> � Sy3 3� <br />