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f ` <br /> 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 5/23/54 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # C 2 q Q C ?RIOR DIST # PRIOR SWEEPS # <br /> WISite Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste invest �azMat ?ipeline :nest <br /> Other Lead Agency Site gency: WQCB DTEPA SC PL Site ater Quality Site ther ?tree Site <br /> DESIGNATED EMPLOYEE # y Cr PRO ELEMENT # ��j r'�) CURRENT STATUS <br /> 7. <br /> NUMBER OF UNITS ( / EPA T_D #: (/ ( Jy INSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> 311LZNG ACKNOWLEDGEMENT: 1, 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 t., the party identified as the BILLING ?ARTY on <br /> the Masterfile Record informat_cn 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, 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 -/-/ Pr_or -/-/ <br /> Fee Amount Amot n_ �a__ Date of Payment Pa,,men-- ^.-pe Receipt 4 Check = Recvd 3v <br />