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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 Change Edit x (PROG4) revised 5/23/94 <br /> 7 FACILITY ID # �� 1 FACILITY NAME /1,,. <br /> RECORD ID # PRIOR DIST # 11JJ�� PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessmen ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> [her Lead Agency Site gency: WQCB DTSC EPA L Site ater Quality Site Lher Type Site <br /> DESIMMTED EMPLOYEE # PROGRAM ELEMENT # 2 G �� CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> .lumber 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 a0 th he work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, S e uid .ederal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property locate at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/si 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 / <br /> / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # <br /> Recvd By <br />