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1 <br /> 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 # R71 `C1n {� FACILITY NAMEI �_ ✓ <br /> RECORD ID # ps 3 ,13 PRIOR DIST # G� PRIOR SWEEPS # <br /> Site Mitigation: , nvironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site l gency: WQCB DTSC EPA L Site ater Quality Site they Type Site <br /> 3/0 <br /> 3/5 <br /> DESIGNATED EMPLOYEE # D PROGRAM ELEMENT # D CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> Number ofTANKS linked to this PROGRAM record <br /> BILLING ACC70WLEDGEMEN'T: 11, 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 /> i <br /> APPLICANT'S SIGNATURE <br /> Tittle: - Date: <br /> AUTHORIZATION TOX <br /> ON: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> theproperty locsite address hereby authorize the release of any and all results, geotechnical data and/oz <br /> environmental/sirmation to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available me it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment a Receipt # Check # Recvd By <br /> 31s <br /> � r <br />