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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 Edic (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR 'DIST 4 PRIOR SWEEPS <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMac Pipeline Invest <br /> ther Lead agency Site gency: WQCB DTSC EPA PL Sitsacer Quality Site 10ther Type Site <br /> DESIGNATED EMPLOYEE # (,;` PROGRAM ELEMENT # r-)14 - CURRENT STATUS <br /> NUMBER OF UNITS EPA ID 4: :NSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 7, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> P.LIS-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 Infor-nation Form. <br /> I also certify chat I have prepared this application and that the work to be performed will be done in accoraance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: 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 is 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 Tame Receipt d deck 4 Recvd By <br />