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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Changer <br /> FACILITY ID # FACILITY NAME AA <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> site Mitigation: 7� Environmental cal Hazardous waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site ( _ EPA L Site ate- Quality Site then Type Site <br /> � CT <br /> DESIGNATED EMPLOYEE # O 6 PROGRAM ELEMENT # Z9.J lJ CURRENT STATUS <br /> NUMBER 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 /> PHSI-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 Forma <br /> I also certify that,I have prepared this application that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes antandards, St <br /> d Sa and,Federal laws. <br /> I <br /> i <br /> APPLICANT'S SIGNATURE <br /> I <br /> I <br /> Title: r; 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 SERVICES ENVIRONMENTAL. HEALTH DIVISION as soon as <br /> it its 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 /> # <br /> i � <br />