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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EVIRoNnNTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> New Change Edit <br /> GENERAL PROGRAM FILE: f�� tel'' <br /> ! FACILITY NAME <br /> / Y _ _` `' <br /> FACILITY ID # 0 ( tiv <br /> G l v q PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # D�)� <br /> Ehe.-MLe.gd <br /> ationHSite <br /> virocmental Assessment /CAP <br /> al Hazardous Waste Invest zMat Pipeline Invest <br /> envy: WQCB DISC <br /> EPA L Site ater Quality Site <br /> then Type Site <br /> Agen <br /> ir <br /> PROGRAM F'T^" # 2�S� �-�`�`rI STATUS <br /> FDESIGNATEDMPLOYEE # VINSPECTION CODE <br /> EPA ID #: <br /> TS : __ <br /> lumber of TANKS linked co this PROGRAM record C <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> identified as the 9ILLING PARTY on <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party <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 /> INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEASEeotechnical data and/or <br /> the property located at the above site address hereby authorize the release of any and all results, g <br /> environmental/site assessmEnt information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and ax Zthe same time it is provided to me or my representative. <br /> prior <br /> DEADLINE DATES: Inspection: <br /> Current <br /> Pa ent Type Receipt # Check # Re-5--d <br /> Fee Amount <br /> Amount Paid Date !ofPay-mennt Ym <br /> �� z ;!�4 <br />