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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ///SITE MITIGATION MASTERFILE RECORD FORM <br /> t <br /> GENERAL PROGRAM FILE: New V Change edit (PROG4) revised 5/23/94 <br /> FACILITY ID # rU�Dn FACILITY NAME fY�� <br /> -7 <br /> RECORD ID # /�!{ / PRIOR DIST # PRIOR SWEEPS 47 <br /> Site Mitigation: nvironmental Assessment1UST,/CA.P cal Hazardous Waste Invest azMat Pipeline Invest <br /> they Lead Agency Site Agency: IRWQTTDTSC EPA L Site aver 2uality Site then Type Site <br /> DESIGNATED EMPLOYEE # i U _FPR SL MENI # �RRENP STATUS <br /> NUMBER OF UNITS : !!! EPA ID #: {{ INSPECTION CODE '3 V v <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-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 Standards, State 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 /> J4 4 6/- <br /> DEADLINE DATES: Inspection: Current / Prior <br /> Fee Amount Amount Paid Date of Payment Payment jpe Receipt # Check # Recvd 3y <br />