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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> V <br /> GENERAL PROGRAM FILE: New Change Edit ! (PROG4) revised 3/23/94 <br /> FACILITY ID # P� /�� 1C� �G \ FACILITY NAME <br /> RECORD ID # V� �l PRIOR DIST # PRIOR SWEEPS <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat ?ipeline Invest <br /> Other Lead Agency SiteAgency: I IRWQC3 DTSC11 EPA L Site ater Quality Sitether Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEME # ���O CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> 'lumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: _, the undersigned owner, operator or agent of same, acknowledge chat all site and/or project specific <br /> PHS-END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING ?ARTY 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 /> 4�APPLICANT'S SIGNATURE <br /> Title: �r '_ 0.�I" 1�e0 o� �9� Date: 7J 300 <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 Type Receipt .': Check # I Recvd 3v <br /> i <br /> 00 <br />