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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> SNVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit n(PROG4) revised 3/23/94 <br /> FACILITY ID # O O e1 O u u O iACILITY NAME <br /> RECORD ID # ^ V s 3 5 y S PRIOR DIST # PRIOR SWEEPS # <br /> its Mitigation: X nvironmental Assessment. ST/CAP coal Hazardous Waste Invest azMat ?ipeLine Invest <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site 'ter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # �-d I <br /> CURRENT STATUS <br /> NUMBER OF UNITS, : EPA ID #: I 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 /> 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 1 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: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of env 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 Type Receipt # Check # Recvd 3v <br /> L. <br /> 519 " ro Azf-b& <br /> 3\Ny ► <br />