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• <br /> SAN JO�IRON IN OUNTY T PUBLIC HEALTH SERVICES <br /> HEALTH <br /> SITE MITIGATION MASTERFILE DIVISION <br /> RECORD FORM <br /> GENERAL PROGRAM FILE: / <br /> New � <br /> _Change <br /> FACILITY ID # ��Edit <br /> FACILITY N (PROG4) rse <br /> RECORD ID q AME evi <br /> � � d 5/23/94 <br /> PRIOR DIST g <br /> PRIOR SWEEPS 4 <br /> its Mitigation: <br /> �� nvimnmental <br /> CherAssessment SCRP <br /> Lead Agency Site gen <br /> t T/ cal Hazardous Waste a <br /> Waste <br /> 1� NQ® zMat <br /> DISC EPA r elfin Invest <br /> PL Site "Or <br /> Quality Site <br /> Cher Type Site <br /> DESIGNATED EMPLOYEE # <br /> NUMBER OF UNITS PROGRAM ELEMENT ✓'�J(J CURRENT STATUS <br /> EPA ID g: <br /> Number of TANKS linked to this PROGRAM record INSPECTION CODE <br /> BILLING ACKNGNLEOGEMENT: I, <br /> the undersigned owner, operator or agent of same, <br /> PHS-ERD hourlY charges associated with this facility or activit w' acknowled e <br /> Y all a that all site and/oz project specific <br /> the Masterfile Record Information Form. be billed to the <br /> party identified as the BILLING PARTY on <br /> I also cer-",-y that I have prepared this application <br /> and that the work to be performed will be done in accordance with all SAN <br /> JOAQU*3 COUNTY Ordinance Codes and Standards, State and Federal l laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the <br /> anOVe• <br /> the property located at the hhen applicable, I, the owner, operator or agent of same; of <br /> above site infoe address hereby authorize the release of any and all results, geotechnical data and/or <br /> it is available and at the sam <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ae soon as <br /> e time it is provided to me or my representative. <br /> d <br /> DEADLINE DATES: _T:s. bion: Current <br /> , ' . <br /> t Paid ate Of Payment 7a'.�_ :`+pe '____ t 4 Check 3 Re d By <br /> � n <br />