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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SITE MITIGATION MASTERFILH RECORD FORM GENERAL PROGRAM FILE: New Change Edit J FACILITY NAME FACILITY ID # � � � I � `�� Piro ^g� I �% PRIOR DIST # RECORD ID # S D b ite Mitigation: y vironmental Assessment /� ff WQCB DTSC EPA ther Lead Agency Site envy: (PROG4) revised 5/23/94 7-15 PRIOR SWEEPS # Hazardous Waste Invest PROGRAM ELEM DESIGNATED EMPLOYEE # D �� I NUMBER OF UNITS EPA ID #: 1 Number of TANKS linked to this PROGRAM record Site Quality Site CURRENT STATUS INSPECTION CODE : t pipeline Invest Type Site ifi BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that dentifsite iedas d/or9projectLIGPspRTYec one PHS-EHD hourly charges associated with this facility or activity will be billed to the party the Masterfile Record information Form. I also certify that I have Prepared this application and that the worktobe performed will be done iz accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: / RMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of AUTHORIZATION TO REi.R7LC the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN C JN Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. DEADLINE DATES: Inspection: Fee Amount Amount Paid 2" • 2 :Ta Current -/-/- Date /Date of Payment payment Type -7- Prior -/-/- /Receipt Receipt # Check # Recvd BY l l 6WIA