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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 5/23/94 <br /> FACILITY ID # 'Y� u 1 ` 3 FACILITY NAME z';V� <br /> RECORD ID # ` J C-. � PRIOR DIST # PRIOR SWEEPS # <br /> /. <br /> Site Mitigation: Y Environmental Assessment ST/CAP cal Hazardous Waste Invest —Mat Pipeline Invest <br /> other Lead Agency Site gency: WQCB DTSC EPA L Site [later Quality Site ther Type Site <br /> 'gvi <br /> DESIGNATED EMPLOYEE T# <br /> PROGRAM ELEMENT # CURRENT STATUS <br /> :LUMBER 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, ac edge that all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be bi 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 t the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State a ederal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date-.— <br /> AUTHORIZATION <br /> ate: <br /> AUTHORIZATION TO RE E INFORMATION: In addition to the above, when applicable, r, the owner, operator or agent of same, of <br /> the property loc ed at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmenta ite 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 # Recvd By <br />