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F � - <br /> SAN JOAQUIN COUNTY PUBLIC MUTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New ✓ Change Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID <br /> FACILY NAME <br /> RECORD ID PRIOR DIST <br /> # <br /> F PRIG SWESYS # <br /> its Mitigation: vironmental AssessmentST CAP <br /> / cal Hazardous Haste Invest zMat Pipeline Invest <br /> ther Lead Ag—' Icy Site gency: HQ® DT$O EPA <br /> L Site stet Quality Site Gher type Site <br /> DESIGNATED EMPLOYEE # �' �] PROGRAM ELEMENT # <br /> / / rI CDRRENT STATUS <br /> NUMBER OF UNITS ' EPA ID #: / INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACRNDHLEDGLMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/ 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 SIGNATURE - <br /> Title: <br /> 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 TOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMEN'T'AL 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 Aeceipt IF 'Check p Recvd By <br /> c�Ls/k <br /> ZIP(- y <br />