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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 Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # L.fl O O tC/ FACILITY NAME <br /> RECORD ID # S�IIQ 3 PRIOR DIST # PRIOR <br /> SWEEPS- <br /> ite Mitigation: nvironmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> O <br /> ther Lead Agency site Agency: IRWQCB DTSC EPA L Site Faler Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # "/ -a— PROGRAM ELEMENT # Cfsrtj CURRENT STATUS <br /> NUMBER OF UNITS : / I EPA ID #: (( INSPECTION COCE <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 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 /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operacor or agent rnoP- <br /> D <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical Xi r <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as o�nzo <br /> it is available and at the same time it is provided to me or my representative. �r-r qi <br /> PU c BE�ALTH S VICES <br /> ENVIRONMENTAL HEALTH�NISION <br /> DEADLINE DATES: Inspection: Current / <br /> Prior <br /> Fee Amount Amount ?aid Date of Payment Payment Type Receipt 4 �2i eck # Recvd By <br /> 114 r� q� <br />