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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 V Change Edit (PROG4) revised 5/23/54 <br /> FACILITY ID # _ O j\ FACILITY NAME <br /> V � <br /> RECORD ID # C I 1A 1 PRIOR DIST # I PRIOR SWEEPS <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> Cher Lead Agency SiteAgency: I 1RWQCB DTSC EPA ::FLE aQuality SiteOther Type Site <br /> DESIGNATED EMPLOYEE # 7 7-PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: v INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <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 faci_icy or activity will be billed t., the party identified as the BILLING ?ARTY_ on <br /> the Masterfile Record Information Form. <br /> 1 also certify that 1 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 / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # I Recvd 3y <br /> cv— <br />