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PAYMENT RECEIVED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NOV 2 9 2001 ENVIRONMENTAL HEALTH DIVISION SITE MITIGATION MASTERFILE RECORD FORM SAN JUAt;i(''I OUNJY PURI ICM I'�I d RVICES FNVPLc r;i i �i, ingSlJPi GENERAL PROGRAM FILE: New-X—Change Edit (PROG4) revised 5/23/94 FACILITY ZD # 00/3�9� FACILITY NAME RECORD ID # /0'0 PRIOR DIST q PRIOR SWEEPS # Site Mitigation: ironmental Assessment /CAP al Hazardous Waste Invest zMat Pipeline Invest [her Lead Agency Site / \ ency: WQCB DISC EPA Site ater Quality Site I 10ther Type Site DESIGNATED EMPLOYEE qJ Y. PROGRAM ELEMENT q 4 5 CURRENT STATUS /� NUMBER OF UNITS I SPA ID Y: INSPECTION CODE : 36 `��) Number of TANKS linked to this PROGRAM record BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on the Masterfile Record Information Form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. 1 �� b w DEADLINE DATES: Inspection: Current / / Prior Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By v��c4 2i 30 0� ✓ /5 %q 7