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R <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ECE VED <br /> ENVIRONMENTAL HEALTH DIVISION SUN 2 4 2003 <br /> SITE MITIGATION MASTERFILE RECORD <br /> PUB IcHi jHEA 0 Svi <br /> Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change <br /> FACZLITY ID # 001 FACILITY NAME <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # �D a <br /> i[e Mitigation: ironmental Assessment /CAP <br /> al Hazardous waste Invest zMat Pipeline Invest <br /> ther Type Site <br /> ther Lead Agency Site envy: <br /> WQCg DTSC EPA L Site ater Quality Site <br /> nn PROGRAM ELII�NT # �9 V NT STATUS <br /> FS : <br /> MPLOYEE # V <br /> INSPECTION CODE <br /> TEPA ID #: / <br /> Number of TANKS linked [o this PROGRAM <br /> record 5 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-ZHD 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 /> Z 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 1 1 <br /> ` V Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: n addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> eotechnical data and/or <br /> the property located at the abov ite address hereby authorize the release of any and all results, g <br /> environmental/site assessmen information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon as <br /> it is available and at same time it is provided to me or my representative. <br /> Prior <br /> DEADLINE DATES: Inspection: Current <br /> Amount Paid Date of payment Payment Type Receipt # Check # Recvd BY <br /> Fee Amount <br />