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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PAWEV,41 <br /> SITE MITIGATION MASTERFILE RECORD FORM RECEIVED <br /> FEB 14 2000 <br /> SAN JUA(.]UIN COUN fY <br /> GENERAL PROGRAM FILE: New- Change Edit EiVVIPU6M0 <br /> MEMQA <br /> II_�M3/94 <br /> HEALTH W <br /> FACILITY ID # ~//�� u FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWMPS <br /> Site Mitigation: Environmental Assessment /CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> 'I <br /> Other Lead Agency SiteAgency: W;3 DTSC EPA L Site �ater Quality Site ITIher Type Site <br /> DESIGNATED EMPLOYEE $ ( �/n PROGRAM <br /> ELr 4 L SU c;= STATUSNUMBER OF UNITS tt!! EPA ID I: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : <br /> 3ILLING 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 that work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State an ederal laws. <br /> i <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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee amount Amount Paid Date of Payment Payment Type Receipt Check 4 Recvd By <br />