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r SAN .iOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New__V Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # °G L 1 PRIOR DIST # C PRIOR SWEEPS # <br /> 113 X:t �7 <br /> .Site Mitigation: Environmental Assessment13ST/CAP Wcal Hazardous Waste Invest LzMat Pipeline Invest <br /> Other Lead Agency Site ency: �RWQCB DTSC EPA L Site .ter Quality Site I 10ther Type Site <br /> ,DESIGNATED EMPLOYEE # a�� PROGRAM ELEMENT # 2,q!50CURNT <br /> D RESTATUS <br /> NUPSER OF UNITS : �v EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM recon! <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 Farm. <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,fand Federal laws. <br /> y V <br /> APPLICANT'S SIGNATURE <br /> Title: pate: <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 SANT 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 Type Receipt # Check # Recvd By <br /> �/ <br /> *molt <br />