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STAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: (, Change Edit V (PROG4) revised 5/23/94 <br /> FACILITY ID # �i� O l FACILITY NAME <br /> RECORD ID # D` 4 A PRIOR DIST # PRIOR SWEEPS # `Y <br /> Site Mitigation: Environmental Assessment ST/CAP ocal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency Site gency: 1-/" WQCBI i DTSC EPA. L Site 'ater Quality Site Other Type Site <br /> DESIGNATED EMPLOYEE # ( ` FPROGRAM ELEMENT # CURRENT STATUS <br /> NUMBER OF UNITS le EPA ID n: 1�a INSPECTION CODE U <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, oper=ator or agent of same, acknowledge that all sate 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 INFORKkTION: In addition the abo-: Shen apol_cable, the =_stD_ or agent „r same, of <br /> _ _ , <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 REALT7 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 /> I <br /> -T <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # I Check # Recvd By <br /> �l� l t-[L :7 ti <br />