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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 ?ROG4) revised 3/23/94 <br /> ?ACILITY iD # QD FACILITY "I"'-- Tri ,-�V- & 3 <br /> RECORD ID # Sa `7 Q a s{ PRIOR DIST # ?RIOR SWEEPS # <br /> Site Mitigation: �nvLronmenral Assessment ST/CAP Local 'Hazardous :Taste Invest �azMat Pipeline invest <br /> Other Lead .Aaencv Size �gency: jX, WQC3 DTSC EPA L Site ater Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # TPROGRAMELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE Q U <br /> Number of TANKS linked to this 'PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all size 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 ?ARTY 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 / <br /> Prior <br /> Pee Amount7 <br /> Amount ?aid Date of Payment Payment —ype Receipt = `:eco # Recvd 3y <br />