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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 Change <br /> Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> / <br /> RECORD ID # PRIOR DIST # PRIOR (ZEPS # <br /> � � a I/�' <br /> ite Mitigation: Environmental Assessment /CAP al Hazardous Waste Irnest zMat Pipeline Invest <br /> --F/` they Lead Agency Site envy: � kWQCB DTSC EPA L SiteTter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # 1 y 04IFPROGRAM ELEMENT # 2 l'S9 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record ;p' <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 /> Date: <br /> Title: <br /> AUTHORIZATION TO 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 /> Date of Pa t Payment Type Receipt # Check # Recvd By <br /> Fee Amount <br /> Ef;c Yin <br /> 2�7 ' 3Q003 2,5�3 <br />