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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 L'hange Edit (PROG4)) revised 5/23/94 <br /> FACILITY ID # 9r FACILITY NAME <br /> RECORD IO # `/ // t1 PRIOR DIST # ( V l V`P-RIOR SWEEPS # <br /> Site Mitigation: ironmental Assessment T/CAP cal Hazardous Waste Invest zMaE <br /> es[ <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site star <br /> Quality Site ite <br /> DESIGNATED EMPLOYEE # l 1C PROGRAM ELEMENT 4 CURRENT STATUS <br /> NUMBER OF UNITS : 1111 EPA ID #: 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 he billed to [he party identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this -ISJi.tio. and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards Stat d Federal laws. <br /> APPLICANT'S SIGNATURE : $ <br /> Title: Date: <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 /> DEADLINE DATES: Inspection: Current / / Pr-or <br /> Fee Amount Amount Paid Date of Payment Paymenc =ape Receint # Check # Recvd By <br /> 5 <br />