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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 Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # D /'1 -}' FACILITY NAME L A�� /� ' (U/—'�) <br /> -T <br /> RECORD ID # a O !�•3 3 q 9/ PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site Agen7 �WQCB DTSC EPA L Site ater Quality Site I 10ther Type Site <br /> /3 10 V" <br /> �G -312 <br /> �3►S <br /> DESIGNATED EMPLOYEE # O PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> :lumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, 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 that I have prepared this application and that the work to be Derformed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Fede aws. <br /> APPLICANT'S SIGNATURE : <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE RMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at t e above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site asse sment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and a 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 a Receipt Check # Recvd By <br />