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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change 1 Edit (PROG4) revised 5/23/94 <br /> 12 <br /> FACILITY IDIl LITY NAME 0 f <br /> FACI <br /> RECORD ID # 0�! T�� PRIOR DIST # PRIOR SWEEPSL# �jly <br /> Sit. Mitigation: nvironmental Assessment DS <br /> T/CAP cal Hazardous Waste Invest azMat Pipeline :n,est <br /> Cher Lead Agency Site ency: WOCB DISC EPA PL Site ater Quality Site Cher Type Site <br /> 7/4�7 jy" <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # 7 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-RHD 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: Date: ZO O <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, bpe�fater, or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all resulfii-. gtptechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH-BAVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. gy� 6 6j 1SAN <br /> v17!I �W <br /> ANVR FSEMH " ERVCS' <br /> 2i LU Psi <br /> DEADLINE DATES: Inspection: Current / Prior _/_/ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # '/ Check <br /> ry# Recvd /By <br />