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s <br /> 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 /> FACILITY ID # L C� FACILITY NAME <br /> RECORD ID # 6 J �JZ PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: > nvironmental Assessment ST/CAP cal Hazardous Waste Invest —Mat Pipeline Invest <br /> Other Lead Agency SiteAgency: �-WQCB DTSCT <br /> EPA PL Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # /J 7 PROGRAM ELEMENT # �G / TCURRENT STATUS <br /> NUMBER OF UNITS �( EPA ID #: 1 {0 INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : )K UN-r81 <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 S andards, State and Fe ral laws. <br /> APPLICANT'S SIGNATURE <br /> Title: P(3 C HEMI S i 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 /> J NU <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Z3y z3v lbZ3 S losvzo <br /> IDI23�`iS <br />