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• <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM _ <br /> (PROG4) revised 5/23/94 <br /> Change Edit <br /> GENERAL P7# a� <br /> / F FACILITY NAME?AGILITY �OPRIOR SWEEPS A <br /> 7 PRIOR DIST %RECORD 3Pipeline Invest <br /> it, Mitigation: nvizonmental Assessment ST/CAP <br /> Cal Hazardous waste Invest azMac <br /> Y <br /> WQCB DISC EPA L Site at <br /> then Lead Agency Site gency: <br /> Quali[y Site Cher Type Sice <br /> n /3l D <br /> Sc . BIZ <br /> 3�5 <br /> =TMIKSI..ked <br /> � PROGRAM EL>S1E<�I # . CURRENT STATUS <br /> lJINSPECTION CODE <br /> EPA IDo this PROGRAM record <br /> erator or agent of same, acknowledge that all site and/or project specific <br /> 3ILLING ACKNOWLEDGEMENT: I, the undersigned owner, op <br /> identified as the BILLING PARTY on <br /> PHS-ERD hourly charges associated with this facility or activity will be billed to the party <br /> the Masterfile Record Information Form. <br /> I also certify chat 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 /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the ower, 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 /> Pr-:or <br /> DEADLINE DATES: Inspection: Current / <br /> RecvdEee Amount Amount Paid Dace of Payment Payment Type Receipt 4 Check N By <br /> '� I � z ✓ �-3 g �i, <br />