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F 1 A _ <br /> Wii►' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit y� (PROG4) revised 5/23/94 <br /> FACILITY ID # �.� f jC7 y FACILITY NAME <br /> RECORD ID # 5 �n �y PRIOR DIST # JJ� PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessmen ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> other Lead Agency Site ge�- WOCB DTSCF EPA L Site ater Quality Site ther Type Site <br /> �g <br /> DESIGNATED EMPLOYEE T# ,Arq5 PROGRAM ELEMENT # Z �� CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowl that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be bille the party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application ata th he work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, S e bid ederal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TXatthe <br /> TION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property loe site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/sformation 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 # Recvd By <br />