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c <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />12 <br />GENERAL PROGRAM FILE: New Change Edit <br />(PROG4) revised 5/23/94 <br />FACILITY ID # <br />O V' `�1 ` <br />FACILITY NAME <br />— diw&, /�/� f_/ <br />/G <br />RECORD ID # <br />Receipt # <br />PRIOR DIST # <br />Recvd By <br />PRIOR SWEEPS # <br />3io <br />DESIGNATED EMPLOYEE # U6 O PROGRAM ELEMENT # I Z q. q I CURRENT STATUS <br />NUMBER OF UNITS EPA ID #: <br />Number of TANKS linked to this PROGRAM record <br />INSPECTION CODE : <br />BILLING ACFNOWLEDGEMENT: 1, 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 />APPILICANT'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 / / Prior —/—/ <br />Site Mitigation: <br />Amount Paid <br />Environmental Assessment <br />ST/CAP <br />Receipt # <br />cal Hazardous Waste Invest <br />Recvd By <br />�azMat Pipeline Invest <br />Other Lead Agency Site <br />gency: <br />�WQCB <br />DTSC <br />EPA <br />kL Site <br />�ater Quality Site <br />10ther Type Site <br />3io <br />DESIGNATED EMPLOYEE # U6 O PROGRAM ELEMENT # I Z q. q I CURRENT STATUS <br />NUMBER OF UNITS EPA ID #: <br />Number of TANKS linked to this PROGRAM record <br />INSPECTION CODE : <br />BILLING ACFNOWLEDGEMENT: 1, 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 />APPILICANT'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 / / Prior —/—/ <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />,d� / goo ��o <br />