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J <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION - <br /> SITE MITIGATION MASTERPILE RECORD FORM <br /> GENERAL PROGRAM FILE: He e Edit <br /> /{,�(,y / (2ROG4) revised 5/23/94 <br /> FACILITY ID # U " 00 S FACILITY NAME <br /> RECORD ID # UUUQ j a��1I q PRIOR DIST # N. 'PRRIOR SWEEPS Gx t-YJ <br /> Site Mitigation: 'ronmental Assessment ST/CAP cal Haza::: 4azMat Pipeline invest <br /> Other Lead Agency Site ency: I IRWOCB DISC EPA L Site ater Quality Site that Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # y7 L/ / CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: C/ J IISPECTION 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 specif'_c <br /> IFS-EHD hourly charges associated with this facility or activity will be billed to the party identi`__ed as the BILLING PARTY on <br /> the Masterfile Record Infprmatioa Form. <br /> I also certify that I have prepared this application and that the work to be performed will be done is 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, 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 # Retvd By <br /> 1'7- ✓ <br />