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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> S ( <br /> GENERAL PROGRAM FILE: New v i 1ti L l 1'� <br /> Change_Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # (1 FACILITY NAME ��'� / 1 WCiG�V•�/�t7Q�ly./it� /� <br /> RECORD ID # \ J� G V� C� 1 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment k <br /> T/CAP Local Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency SiteAgency: I IRWQCB DTSC EPA [PL Site ater Quality SiteOther Type Site <br /> ` <br /> DESIGNATED EMPLOYEE # <br /> L PROGRAM ELEMENT # CURRENT STATUS T <br /> NUMBER OF UNITS : EPA ID #: 1 p INSPECTION CODE 7 U <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 /> DEADLINE DATES: Inspection: Current _/ / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Rece_pt # I Check # Recvd By <br /> 3L 5- 3 L kit <br />