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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 / r� /Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID FACILITY NAME /a� <br /> RECORD ID # /tel D 5/ & Lf �/ PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP ocal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency SiteAgency: WQCB DTSC EPA L Site Faler Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # ( \ �J{�[ PROGRAM ELEMENT # / VOW CURRENT STATUSNUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 chat 1 have prepared this application and chat 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: Dace: <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 # Recvd By <br /> / f -3/6 C) /V <br />