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y _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> " SITE MITIGATION MASTERFILE RECORD FORM <br /> _GENERAL PROGRAM FILE: New �� Change Edit (PROG4) revised 5/23/94 <br /> G, <br /> FACILITY ID # DD / FACILITY NAME <br /> RECORD ID # 32_ PRIOR DIST # PRIOR SWEEPS # <br /> r: <br /> Site Mitigation: Environmental Assessment ST/CAP Eocal Hazardous Waste Invest 4azMat Pipeline Invest <br /> / Other Lead Agency Site gency: WQCB DTSC EPA PL Site ater Quality Site Cher type Site <br /> DESIGNATED EMPLOYEE # 2 PROGRAM ELEMENT # 12,9 �� CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> ',,BILLING ACKNOWLEDGEMENT: I, 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 /> 13 <br /> APPLICANT'S SIGNATURE �'y ' r 199/ <br /> "UBLIC HEAL-r,1.t S <br /> ..,j„I, <br /> Date: 7 VVIR©NMENTgL I{'EA l7H UIVf$IpIV <br /> Title: i, <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 Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> - ��3µ—. �/a-r Fri � ✓ �` �tai” (->� <br />