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• <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> J <br /> GENERAL PROGRAM FILE: _ New . Change Edit (PROG41 revised 5/23/94 <br /> FACILITY IO # FACILITY NAKA <br /> RECORD ID # PRIOR DIST # ✓✓✓LWWV!!! VV I01V ,1 PRIOR SWEEPS # VVV <br /> Site Mitigation: Envircnmeoral Assessment T/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DISC EPA L Site ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # �/ Z PROGRAM ELEMENT # Z�V D ==RENT STATUS <br /> NEER OF UNITS EPA ID #: INSPECTION CODE OO <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 Farm. <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 /> XAPCANT'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 SERVIC=S 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: Cirrent / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check # Recyd By <br />