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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 NAMED �T/7 5/ ►""� <br /> RECORD ID PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline invest <br /> other Lead Agency Site envy: WQCB DTSC EPA L Site ater Quality Site 10 <br /> ther Type Site <br /> DESIGNATED EMPLOYEE # OV PROGRAM ELEMENT # j��CIRP= STATUS <br /> -NUMBER OF UNITS 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 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 a 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: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addit n to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site addre hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information SAN JOAQUIN COU,'T Y PUBLIC IFAL A SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it s provided to me or my representative_ <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Payment Type Receipt # Check # Recvd By <br /> Fee Amount Amount Paid Date of Payment <br />