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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 V Change V Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # (/p /_ FACILITY NAME g" <br /> RECORD ID # � PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment i UST/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site gency: WQCB DTSC EPA kL Site �ater Quality Site they Type Site <br /> 11 <br /> Ito <br /> SG�3cz <br /> �31s <br /> DESIGNATED EMPLOYEE # O(,,8'� PROGRAM ELEMENT # Z +.�5 CURRENT STATUS <br /> NUMBER OF UNITS : EPA ID #: INSPECTION CODE <br /> ,lumber 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 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 nd that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, St a and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 /> L,�W� I38o�9 <br /> DEADLINE DATES: Inspection: Current / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3M (0q <br /> Il � % <br />