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0 ON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTEEFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New <br /> Change Edit <br /> (PA0G4) revised 5/23/9q <br /> FACILITY ID N }-p p <br /> J �/76( <br /> fEFAECIL17Y <br /> RECORD ID p / <br /> R . <br /> PRIOR DIST p <br /> PRIOR SWEEP p <br /> ite Mitigation: vimnmental Assessment <br /> ST/CAP cal Hazardous Waste Invest <br /> k F� I <br /> azMat Pipeline Invest <br /> ther Lead Agency Site <br /> gency: WQCB DISC EPA L Site <br /> atez Quality Site ther <br /> Type Site <br /> ffDESIGMATED qPROGRAM ELEZ-1ENT k d- <br /> I (� CURRENT STATUS <br /> EPA ID q: <br /> INSPECTION CODE <br /> d 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 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: <br /> 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 DrvISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / / <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Pa ent <br /> ym Type Receipt p Check p Recvd By <br /> to j L <br />