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j� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SITE MITIGATION MASTERFILE RECORD FORM am GENERAL PROGRAM PILE: New Change Edit ' (PROG4) revised 5/23/94 ( FACILITY ID # FACILITY NAME Uh.- I(' „/ _1„ , 6 WE RECORD ID # �� ,L-� \ PRIOR DIST # PRIOR �SWEE-PPSS ## Site Mitigation: vironmental Assessment ST/CAP ocal Hazardous Waste Invest azMat Pipeline Invest 11 Cher Lead Agency Site envy: WQCE DISC SPA PL Site --r Quality Site ther Type Site DESIGNATED EMPLOYEE # PROGRAM ELEMENT # C `URRENT STATUS NUMBER OF UNITS EPA ID #: V INSPECTION CODE 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 D Pson as it is available and at the same time it is provided to me or my representative. FIY,�1I�p/1�L1v Ep F J AN 5 2001 DEADLINE DATES: Inspection: Current / / Prior / /_TopgNE LTH SERVICES NTAL HEALTH DIVISI Fee Amount Amount Paid Do" of Payment Payment Type Receipt # Check # Recvd By OCA 2 00 1 1-5-DI