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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 Change Edit (PROG4) revised S/23/94 <br /> FACILITY I0 # $I }J('�J FACILITY NAME / / q <br /> RECORD ID # O v ? PRIOR DIST # V PRIOR SWEEPS # <br /> Site Mitigation: nviro=ental Assessment T/CAP cal Hazardous Waste Invest as.Mat Pipeline Invest <br /> Other Lead Agency Site envy: WQCB DISC EPA L Site -ter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # / / PROGRAM ELEMENT # S� CURRENT STATUS <br /> NUMBER OF UNITS ",VVV EPA ID #: C. 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 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 /> ��r;4y�r?xj`I;s•;4�1 <br /> APPLICANT'S SIGNATURE <br /> APR 12 1999 <br /> Title: Date: <br /> PU3UC HEA0H SEHVICEt. <br /> NVIRONMENTAJ !-!rAi 1'H nl\9F <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 /> L (JlJ7� c <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 4' r ,� <br />