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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL REAL—,A DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> V <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised <br /> S/23/44 <br /> FACILITY ID # FACILITY NAME Q Cl..�.T Q'rp <br /> EE <br /> RECORD ID # PRIOR DIST # ?P,I OR SWc^EPS '� <br /> ite Mitigation: nvironmental Assessment ST/CAP coal Hazardous Waste Invest azMat :, <br /> Plpe__le InveS[ <br /> �ther Lead Agency Site gency: WQ® DTSC FPA PL Site ater Qualit Site <br /> Y Other Type Site <br /> DESIGNATED EMPLOYEE_# PROGRAM ELEMENT : �l �j5 CURRENT STATUS . <br /> NUMBER OF UNITS. : �( EPA ID 4: / V INSPECTION CODE <br /> `]umber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge chat all site and/or project specific <br /> PHS-EHD hourly charges assoc_aced with this facility or activity will be billed to the parcy identified as the BILLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that 1 have prepared this apnlicaclon and chat 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 apnlicable, I, the owner, ooerator or agent of same, of <br /> the property located at the above site address hereby authorize the release of anv 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 cc me or my representative. <br /> DEADLINE DATES: inspection: current / ( Prior / <br /> Fee Amount Amount Paid Daae of Payment Payment Type Receipt # Check # Recd By <br /> 31-5' 3 � 7 27 /a �� 30675 <br />