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SAN JOAQUIN COUNTY PUBLIC i ALTH SERVICES <br /> ENVIRONMENTAL HEALTIA DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change <br /> Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> PRIOR DIST # PRIOR EPS # <br /> RECORD ID # <br /> ite Mitigation: <br /> ironmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Kthen Lead Agency Site envy: WQCB OTSC EPA L Site ater Quality Site ther Type Site <br /> �� PROGRAM <br /> DESIGNATED EMPLOYELEME NT # 2� / CURB ANT STATUS <br /> EE # 0 <br /> EPA ID #: INSPECTION CODE <br /> NUMBER OF UNITS <br /> :Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMZNT: 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 /> d <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and that the work 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 /> Date: <br /> Title: <br /> AUT'rIORIZATION TO . <br /> 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 /> s soon as <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a <br /> it is available and at the same time it is provided to me or my representative. <br /> / Prior <br /> DEADLINE DATES: Inspection: Current / <br /> Fee Amount Amount Paid <br /> Date of Payment Payment Type Receipt 4 Check # Recvd By <br /> 30-a3 ;� " 253 <br />