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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change <br /> FACILITY ID # &Z9 <br /> 'n C3 FACILITY NAME /A/�Ez <br /> V O PRIOR DIST # !/ PRIOR SWEEPS # <br /> RECORD ID # <br /> its Mitigation: ,i,, mental Assessmen ST/CAP ...I Hazardous Waste Invest azMat Pipeline Invest <br /> the, Lead Agency Site envy: <br /> WQCB DTSC EPA L Site ate. Quality Site Cher Type Site <br /> PROGRAM ELEMENT # �y✓ SVT STATUS <br /> D <br /> ESIGNATEDLOYEE # (� (� / <br /> INSPECTION CODE <br /> EPA ID #: <br /> 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 /> identified as the BILLING PARTY on <br /> PHS-EM hourly charges associated with this facility or activity will be billed to the party <br /> toe Mascerfile Record :_formation Form. <br /> i also certify that I have prepared this application and that the work to be oerformed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICAN/T''S SIGNATURE : <br /> Title: <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 /> in <br /> to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site assessment <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # <br /> Recvd By <br /> 9 <br /> �,� i DY16 <br />