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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASiERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New /\ Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ironmenta1 Assessment ./CAP Local Hazardous Waste Invest zMat Pipeline Invest <br /> Other Lead Agency Site ency: WQCB DTSC EPA L Site �Water Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # 1 0 PROGRAM ELEMENT # (ASO CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING aC TOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> ?HS-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 I <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INF ION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site arse ment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available an 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 By <br />