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d <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION II <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> II <br /> l <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5123/94 <br /> FACILITY ID FACILITY NAME <br /> RECORD ID # /� r PRIOR DIST # PRIOR SWEEPS # <br /> I, <br /> ii <br /> Site Mitigation: Environmental Assessment [IST/CAP boral Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency Site envy: WQC9 DISC EPA L Site Ater Quality Site Cher Type Site <br /> I! <br /> DESIGNATED EMPLOYEE # [ � /l <br /> PROGRAM ELEMENT' # t `J CURRENT STATUS is <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record I <br /> Ij <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 that the work to be performed will be done in accordance with fall SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> I <br /> APPLICANT'S SIGNATURE <br /> Title: Date: I� <br /> I� <br /> II <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. II <br /> -5--7 S ji <br /> DEADLINE DATES: Inspection: current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check 4 Recvd Hy <br />