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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 # FACILITY NAME / //]AI <br /> RECORD ID # 2 1 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment /CAP cal Hazardous waste Invest �—Mat Pipeline Invest <br /> Other Lead Agency Sitegency: WQCB DTSC EPA L Site ater Quality Site10ther Type Site <br /> 31v <br /> SC: �3►z <br /> �3lS <br /> DESIGNATED EMPLOYEE # �rj� TPRWLAM ELEMENT # 1 2_1_5 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 11, 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 thewor o be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal ws. <br /> 'V <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFO ION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the ove site Zaddress hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessm t information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at th same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / ?rior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Re�clvd By <br />