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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New O Change Edit (PROG4) revised 5/23/54 <br /> FACILITY ID # FACIIILITY NAME S 1 CGU <br /> RECORD ID # /✓pPRIOR DIST # PRIOR SWEEPS <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest kzMac Pipeline Invest <br /> ther Lead Agency SiteAgency: kCB /v DTSC EPA L Site ater Quality Site ther njpe Site <br /> 7 <br /> DESIGNATED EMPLOYEE # V ZJ PROGRAM ELEMENT # 2 l �j 9 CURRENT STATUS <br /> YUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> :lumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 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 ?ARTY 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�73weT <br /> r <br /> APPLICANT'S SIGNATURE <br /> k�� <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INRMATION: 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 /> Y 7 &70 <br /> DEADLINE DATES: Inspection: Current / Prior _/_/ <br /> Fee Amount Amount ?aid Date of Payment Payment Type Receipt # Check # Recvd 3v <br />