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SAN <br /> JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES <br /> ENVIRONMENTAL. HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: <br /> New Change <br /> Edit <br /> FACILITY ID # FACILITY NAME O IS-7 (PROG9) revised 5/23/99 <br /> Z� be/—T-,+ <br /> RECORD ID # RJ p 20 sa3 a--t <br /> PRIOR DIST # <br /> PRIOR SWEEPS # <br /> Iq/q f�.qR r <br /> its Mitigation: <br /> ironmental Assessment ST/GAP <br /> al Razardoua Waste Invest <br /> Gher Lead Agency Site azMat Pipeline Invest <br /> ency: WQCB DISC <br /> EPA Site <br /> ater Quality Site <br /> they Type Site <br /> Sc = 310 <br /> rofTAUM <br /> !t <br /> E # L <br /> PROGRAM ELEMENT # Z <br /> f 5V CURRENT STATUS <br /> �� EPA ID #: <br /> INSPECTION CODE <br /> ked to this PROGRAM record : <br /> BILLING <br /> ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project ecific <br /> PNS-EHD hourly charges associated with this facility or activity will be billed to the party <br /> the Masterfile Record Information Form. identified as the BILLING PARTY on <br /> I also certify that I have prepared this application and that the work to be performed will be done <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. in accordance with all SAN <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 <br /> it is a»ilable and ac thn saob r„m it is provided to mHEALTH DIVISION a9 soon a9 <br /> e or my representative. <br /> M <br /> : Inspection: Curren[ / / Prier Amount Paid Date of Payent Payment Type Receipt # Check # Recvd Ey <br /> �a-�q- lal�'lD� ✓ �I os� <br /> 7iL la��or <br />