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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change Edit <br /> FACILITY ID # NOl Ai' le 5 FACILITY NAME <br /> RECORD ID # D,/�1 g'� PRIOR DIST # PRIOR SWEEPS <br /> --- <br /> Site Mitigation: Environmental Assessment 1UST/CAP cal Hazardous Waste Invest �azMat Pipeline invest <br /> other Lead Agency Site gency: WQCH DISC EPA L� SiteTTater Quality Site Lher Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT SENT 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, 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 SIGNATURE <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, �pez@XrjiPrrIrnt of same, of <br /> the property located at the above site address hereby authorize the release of any and all resu;tfE �h ical 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. S E P 3 O 2002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISP;)N <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check It Recvd By <br />