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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 I Change Edit (PROG4 ) revised 5 /23 /94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD IO # 6 D (J q I I PRIOR DIST # PRIORSWEEPS # <br /> its Mitigation : nvironmental Assessment ST/CAP coal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency Site gency : WQCB DISC EPA L Site I ater Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # Li i `1 PROGRAM ELEMENT # . SV CURRENT STATUS <br /> NUMBER OF UNITS l i 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 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 : Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3Sp � Ls 'vjq{a2v3 <br /> L <br /> N2 Ilio/9d <br />