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T. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION it <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> �f <br /> I <br /> GENERAL PROGRAM FILE: New Change /� Edit 11 (PROG4) revised 5/23/94 <br /> if <br /> FACILITY ID # (O W� `T3 FACILITY NAME <br /> RECORD ID # // 9 PRIOR DIST # PRIOR SWEEPS # <br /> CCC111 ccc///���� lV <br /> �I <br /> Site Mitigation: Environmental Assessment ST/CAP al Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site envy: �RWQCB DISC EPA kL Site �ater Quality Site Cher Type Site <br /> q <br /> r � <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT # 7 7� / CURRENT STATUS vc <br /> NUMBER OF UNITS EPA ID #: INSPECTIONI1CODE <br /> If <br /> Number of TANKS linked to this PROGRAM record Ili <br /> i� <br /> 4 <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 /> ;E <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 /> I <br /> VM 7Y <br /> DEADLINE DATE'S: Inspection: Current / / Prior <br /> k <br /> it <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 70. 0AW7L <br /> AR Sjs)a7 <br />.mow,..- - ww wl i,��J�e��i1����1�4ra•. F�.yr.. ... ._ — <br />