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i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION II <br />�I <br />SITE MITIGATION MASTERFILE RECORD FORM <br />x <br />II <br />GENERAL PROGRAM FILE: New Change Edit <br />(PROG4) revised 5/23/94 <br />FACILITY ID # <br />—:309(lFACILITY <br />NAME <br />I <br />II <br />RECORD ID # <br />! q�� G <br />PRIOR DIST p <br />Recvd By <br />PRIOR SWEEPS # <br />a--��? <br />DESIGNATED EMPLOYEE # �{�— PROGRAM ELEMENT # J� 4� CURRENT STATUS <br />NUMBER OF UNITS L V EPA ID #: —_qSPECTION CODE C� <br />Number of TANKS linked to this PROGRAM record <br />I <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 10 the party identified as the BILLING PARTY on <br />I <br />the Masterfile Record Information Farm. I' <br />�I <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. �I <br />APPLICANT'S SIGNATURE : <br />Title: <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabl <br />the property located at the above site address hereby authorize the release of <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH 5 <br />it is available and at the same time it is provided to me or my representative. <br />I, the owner, operator or agent_ofisame, of <br />"J 11_ <br />r3 <br />and all results, ged�chh�ical1,clF�and/ar <br />ICES ENVIRONMENTAL HEALTH'`DIVISION as -soon as <br />GO v <br />DEADLINE DATES: Inspection: Current / / Prior <br />Site Mitigation: <br />Amount Paid <br />Environmental Assessment <br />ST/CAP <br />it <br />Ileceint # <br />1 <br />riocal Hazlardous haste Invest <br />I <br />Recvd By <br />zMat Pipeline Invest <br />a--��? <br />ther Lead Agency Site <br />✓ <br />envy:WQCB <br />5j 3.3 <br />7�- <br />I I <br />DTSC <br />F <br />EPAL <br />lite <br />�ater Quality Site <br />then Type Site <br />DESIGNATED EMPLOYEE # �{�— PROGRAM ELEMENT # J� 4� CURRENT STATUS <br />NUMBER OF UNITS L V EPA ID #: —_qSPECTION CODE C� <br />Number of TANKS linked to this PROGRAM record <br />I <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 10 the party identified as the BILLING PARTY on <br />I <br />the Masterfile Record Information Farm. I' <br />�I <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. �I <br />APPLICANT'S SIGNATURE : <br />Title: <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabl <br />the property located at the above site address hereby authorize the release of <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH 5 <br />it is available and at the same time it is provided to me or my representative. <br />I, the owner, operator or agent_ofisame, of <br />"J 11_ <br />r3 <br />and all results, ged�chh�ical1,clF�and/ar <br />ICES ENVIRONMENTAL HEALTH'`DIVISION as -soon as <br />GO v <br />DEADLINE DATES: Inspection: Current / / Prior <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />it <br />Ileceint # <br />Check # <br />Recvd By <br />a--��? <br />s �� o z <br />✓ <br />5j 3.3 <br />7�- <br />TNV 0095021 j <br />