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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 /Ch..ge_Edit (PROG4) r v'revised E/27/94 <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID N PRIOR DIST R PRIOR SWEEPS A <br /> *, Dth.r <br /> i 'g ion /�, Environmental Assessment T/CAP cal Hazardous Waste Invest azMat.Pip eline InvesC <br /> Lead Agency Site l gency: WQCB DTSC EPA L Site ater Quality Site the r Type Site <br /> �W/ <br /> �3�S <br /> DESIGNATED EMPLOYEE X DW PROGRAM ELEMENT 9 � $O CURRENT STATUS <br /> NUMBER OF UNITS Y/ EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS-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 /> APPDICANT'S SIGNATVRE <br /> j <br /> Title: Date: - <br /> i <br /> AUTHORIZATION TO RE INFORMATION: In addition to the above, when applicable, I. the owner, operator or agent of same, of <br /> the. property to at 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 Tyne Receipt R Check q Recvd By <br />