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SAN JOAQUIN COUNTY.PU13LIC 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 # FACILITY NAME <br /> RECORD ID # PRIOR DIST % ' 'f F^ PTRIOR SWEEPS-## <br /> 11 <br /> Site Mitigation: I nvironmental AssessmentST/CAP cal Hazardous waste I—est zMat Pipeline Invest <br /> Other Lead Agency Site gency: WQCB DISC EPA L Si6( -ter Quality Site Cher Type Site <br /> ( <br /> i <br /> � 3�� <br /> sc — <br /> 312- <br /> )Pr <br /> rZ)Pr <br /> DESIGNATED EMPLOYEE # Q S' PROGRAM ELEMENT % �q,�s CURRENT STANS <br /> NUMBER OF UNITS EPA ID p: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <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 Forma - <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 /> Title: Date: <br /> AUTHORIZATION TO RELEASE INPORM&Tler. In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> theproperty 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 DMSION as soon as <br /> it his 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 # Recd By <br />