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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERPILE RECORD FORM . . <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # YYYY` V �«` Op 1-7 S'7 FACILITY NAME /`/,Kf�7/ 0$'�'- Zj�e3. <br /> RECORD ID # ��" S^ s- PRIOR DIST ## 'ff PRIOR SWEEPS # <br /> ite Mitigation: —ironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency Site g—cy: WQCB DTSC EPA L Si& ater Quality Site they Type Site <br /> � 3io <br /> sc - <br /> 312- <br /> DESIGNATED <br /> izDESIGNATED EMPLOYEE # o&y PROGRAM ELEMENT # 2-1- s CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number 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 cc 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 /> V <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INPORMA 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 Type Receipt # Check # Recad By <br />