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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /v <br /> ENVIRONMENTAL. HEALTH DIVISION ^ n <br /> SITE MITIGATION MASTERFILE RECORD FORM � 11RI/)1Yy'— L <br /> GENERAL PROGRAM FILE: New Change Edit / `-'1 n (PROG4) revised 5/23/94 (I+yM' <br /> FACILITY ID p FACILITY NAME V l /fl(d /�a11/� /�`" <br /> ` Y NvJ/9q <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: !Environmental Assessment ST/CAP ocal Hazardous 'Waste Invest I azMat Pipeline Invest <br /> ther Lead Agency Site envy: WQCB DISC EPA L Site ater Quality Site 10ther Type Site <br /> W UV a 4A <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> ;lumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge chat all site and/or project specific <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the Darcy identified as the BILLING PARTY an <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 /> 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: Curren[ / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment 'type Receipt 4 Check 4 Recvd By <br />