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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> i <br /> GENERAL PROGRAM FILE: New-->!�_Change Edit (PROG4) revised 5/23/94 <br /> .ACILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR DIST # G PRIOR SWEEPS(a / <br /> 1-1 <br /> ite Mitigation: -nvironmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> O <br /> Cher Lead Agency Site ge.^.c. : -wQ DTSC EPA L Site �acer Quality Site tier Type Site <br /> -:: <br /> DESIGNATED EMPLOYEE # L� PROGRAM ELEMENT # —C) <br /> CURRENT STATUS <br /> ;LUMBER OF UNITS EPA ID #: ` INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : <br /> 3ILLING 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 ;cork to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and 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: Clrrent / / Prior / J <br /> —T— <br /> Fee amount ?mount Paid Date of laymen[ Payment Type Receipt # Check # Recvd 3y <br />