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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: <br /> .`k�. FACILITY ID # yam- fS U` $1A FACILI'T'Y NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment- ST/CAP Local Hazardous Waste Invest azMattPipeline-Invest <br /> =-- WQCB DTSC EPAQuality Site Other Type Site <br /> ther Lead Agency Site g <br /> DESIGNATED EMPLOYEE # r PROGRAM ELEMENT # '��L� CURRENT�STATUS <br /> C INSPECTION CODE <br /> NUMBER OF UNITS EPA ID #: -- <br /> o <br /> Number of TANKS linked to this PROGRAM record <br /> L <br /> BILLING ACKNOWLEDGEMENT: I, 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 T.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 - <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 ENV1kONMENTAL HEALTH DIVISION as soon as <br /> i <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 # Recvd By <br /> µ <br /> l { <br />