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ORIGINAL <br /> SAN JOAQUIN COGNTY PUBLIC HEALTH SERVICES <br /> ENVIROI`NHN'IAI. HEALTH DIVISION <br /> SITE MITIGATION MNSTERFILE RECORD FORM <br /> Edit (PROG41 revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change <br /> FACILITY ID # ^ / FACILITY NAME <br /> RECORD ID # �a`l� �f7 3C3 PRIOR DIST # PRIOR SWEEPS R <br /> Site Mitigation: vironmental Assessment T/CAP al Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site 1 ency: NQCS DISC EPA L Site aver Quality Site then Type Site <br /> DESIGNATED EMPLOYEE # D/_ PR '� E71T # 4l"�V CURRENT STATUS <br /> INSPECTION CODE <br /> NUMBER OF UNITS <br /> �J EPA ID #: <br /> Number of TANKS linked to this PROGRAM record Vl O <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned ower, operator or agent of same, acknowledge that all site and/or project specific <br /> identified as the BILLING PARTY on <br /> PHS-EHD hourly charges associated with this facility or activity will he billed to the Party <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and that the wrk to erformed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards. State and Federal la <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE RMATION: In addition co the above, when applicable, I, the ower, operator or agent of same, of <br /> the property located the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site saessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION as soon as <br /> it is available d at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / <br /> / Prior <br /> Fee Amount <br /> Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3o <br />