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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 0-nge Edit (PROG4) revised S/23/94 <br /> FACILITY ID # FACILITY NAME /E�/`^�'�►O <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ZD # <br /> Env iromnental Assessment /CAP al Hazardous waste Invest zMat Pipeline Invest <br /> ite Mitigation:U <br /> they Lead Agency Site <br /> Agency: WQCB DISC EPA L Site ater Quality Site ther Type Site <br /> D� PROGRAM ELEMENT # 3(� c�RRENT�A:US <br /> .......... <br /> DESIGNATED EMPLOYEE # ffGG <br /> INSPECTION CODE <br /> NUMBER OF UNITS EPA ZD #: <br /> Number of TANKS linked co this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: Z, 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 all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURES <br /> Date <br /> Title: <br /> ION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEASE INFO eotechuical data and/or <br /> the property located at the a site address hereby authorize the release of any and all results, g <br /> environmental/site asat t information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> time it is provided to me or my representative. <br /> it is available and the same <br /> / / Prior <br /> DEADLINE DATES: Inspection: Current <br /> FAmount Paid Dace of Pa t <br /> Payment Type Receipt # Check # Recvd BY <br /> Fee Amount <br />