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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 Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID N /l FACILITY NAME KI <br /> RECORD ID # O VA O C PRIOR DIST N PRIOR SWAEPS # <br /> ite Mitigation: nvironmental Assessment T/CAP cal Hazardous Waste InvestzMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQ® DISC <br /> EPA L Site ate- Quality Site ther Type Site <br /> 3io <br /> �3e5 <br /> DESIGNATED EMPLOYEE 4 PROGRAM ELEMENT # �.�(� CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Vumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDrRMENT: 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 he billed to the party identified as the BILLING PARTY on <br /> the Masterfile Record information Forma <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 /> j M <br /> I <br /> Tit Is: 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 /> itis 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 # C,e,k # Recvd By <br /> 2��`i � r z► 5 <br />