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i <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 S/23/94 <br /> FACILITY ID # /^ DD FACILITY NAME01 y <br /> RECORD ID # r S l�-I�✓3 sU� PRIOR DIST ,Y PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMaC.Pipeline Invest <br /> Cher Lead Agency Site gency: WQCS DISC 'c PA L Site ater Quality Site they Type Site <br /> d <br /> SC ai312- <br /> ,315 <br /> DESIGNATED EMPLOYEE # O PROGRAM ELEMENT # Zgso CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked Co this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 11, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS-EHD hourly charges associated with this facility or activity will be billed co 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 1 <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 Typ Receipt # Check # Recvd By <br />