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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//994. <br /> FACILITY ID # 1� b b ` $ 2 3 4!� t�S��/J <br /> tS FACILITY NAME <br /> RECORD ID # O S 2 3 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental AssessmentST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency SiteAgency: gWQC:B1 DTSC EPA L Site �ater Quality Site they Type Site <br /> 3�5 <br /> DESIGNATED EMPLOYEE # Db PROGRAM ELEMENT # �6 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 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 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 /> 1� <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> '_'x <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 /> Fee ,Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> /3l <br /> Cyw tt" 4 3� <br />