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PAYIVIENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM MAY 1 5 2009 <br /> _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised S/23/94 <br /> FACILITY ID p O Q / FACILITY NAW 1t" W-L( r+G✓VGf�l�tl�� <br /> RECORD ID # III A_b Sa q-7-7,T <br /> 1 PRIOR DIST # PRIOR SWEEPS k <br /> 6 (0 �fA' D clolofv S >l <br /> Site Mitigation: !Environmental Assessment ST/CAP cal Hazardous Waste Invest I luam" <br /> Pipeline Invest <br /> Cher Lead Agency Site gency: HQC DISC EPA L Site ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # GI PROGRAM ELEMENT k 6 d CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACOOh'LEDGEIENT: 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 /> APPLICANT'S SIGMA= <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 propercy 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 / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt kCheck # Recvd By <br /> 2 <br /> � a,sie <br />