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r <br /> iy vn �s4 t <br /> v I yh <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONk <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> �P <br /> 1 <br /> GENERAL PROGRAM FILE: New- � ' <br /> Chan4e Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # E]15fl: <br /> NAME <br /> rff p i <br /> RECORD ZD # f �`7, PRIOR SWEEPS # <br /> ite Mitigation: 'ronmental Assessment T/CAU <br /> cal Hazardous waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site': <br /> eR� WQCP j DTSC EPA L Site ater Quality Site they <br /> 1 ape Site <br /> =nked <br /> ;11: � PROGRAM ELEMENT # CURRENT STATUS <br /> EPAID #: <br /> INSPECTION CODE <br /> o this PR <br /> OGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/orro'ect <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the p specific <br /> the Masterfile Record Information Form. Party identified as the BILLING PARTY on <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 /> APPLICANTS SIGNATURE <br /> Title:_ <br /> Date: e <br /> 'ADTHORIZATION TO RELEASE <br /> INFORMATION: In addition to the <br /> above, when applicable, Z, 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 ENVIRONMarIAL 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: I = <br /> nspection: + <br /> Current / / <br /> Prior / / <br /> Fee Amount Amount Paid - - <br /> Date of Payment pa <br /> yment Pe Receipt# Check # Recvd By <br /> O <br /> r <br /> .f.t: <br />