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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FOAM <br /> GENERAL PROGRAM FILE: New ChangeEdit (PROG4) revised 5/23/94 <br /> FACILITY ID # O U / O 3 FACILITY NAME (� <br /> RECORD ID # PRIOR DISI # PRIOR SWEEPS # <br /> Site Mitigation: imnmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> other Lead Agency Site Agency: CB DISC EPA L Site star Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # / �� PROGRAM ELEMENT # Z! lOO CURRENT STATUS <br /> NUMBER OF UNITSy EPA ID #: INSPECTION CODE <br /> Number 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 /> PES-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 In ormation Form. <br /> I also certify that I have repazed this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Code and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE I/ <br /> V <br /> ate: <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to above, when applicable, I, the owner, operator or agent of same, Of <br /> the property located at the above site address hereby autho ize 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 is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount <br /> Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 21177 2�7 - !2 <br />