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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 v Change Edit (PROG4) revised 5/23/94 <br /> ?AGILITY ID # 13 q I FACILITY NAME <br /> RECORD ID # rilA 844-3 PRIOR DIST # ( PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site ( Agency: IRWQCB DTSC EPA L Site �ater Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # L J PROGRAM ELEMENT # �l s CURRENT STATUS <br /> ]UMBER OF UNITS EPA ID #: L INSPECTION CODE c� <br /> :lumber 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 idenc_:ied 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 <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, geotef*,*DSJb&�/`a1d/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALEH6JOP F;Aoon as <br /> it is available and at the same time it is provided to me or my representative. <br /> MAY 2 9 2002 <br /> SAN JOADON <br /> COUN <br /> S VICES <br /> N <br /> ENVI(tO <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check # Recvd By <br />