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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. V Change Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # 7 FACILITY NAME <br /> RECORD ID # ./J� CT PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: nvironmental Assessment ST/CAP <br /> j <br /> zardous Waste Investthey Lead Agency Site gency: WQCB Site ater Quality Site then Type Site <br /> I <br /> DESIGNATED EMPLOYEE # lL.r)� PROGRAM ELEMENT # ��✓ CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: ' INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACIWOWLEDGEMENT: 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, <br /> State and Federal laws. <br /> APPLICANT'S SIGNATURE •/� • � <br /> Title:_ President, WHF, Inc. Date: August 11, 1995 <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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />