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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �YfY <br /> e f ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: . New--Change Edit r °, f <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # I)�p�` 3 717 PRIOR DIST # <br /> / C -PRIOR SWEEPS #' <br /> ite Mitigation: ronmental Ass:_7nt <br /> / ' 1 Hazardous Waste Im.est azMat Pipeline Invest <br /> they Lead Agency Site envy: WQCDISC EPA <br /> L'Site ;'> ater Quality Site ther.Type Site <br /> DESIGNATED EMPLOYEE #, �In PROGRAM ELEMENT # . <br /> CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: <br /> INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT Z, 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 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 /> Title: <br /> 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 HEALTfi SERVICES ENVIRONMENTALHEALTH 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:' Current / / ' <br /> Prior <br /> Fee Amount Amount Paid <br /> --------------------- <br /> Date of Payment Payment Type Receipt# Check # <br /> Recvd By <br /> 9/a/a) <br />