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08/31/2010 10: 28 20946834333 EHD PAGE 02 <br /> SAN JOAQVIN COUNTY PUBLIC HEALTH SERVICES '_, L— YMEN <br /> CE <br /> _ AVEC) <br /> i ,ENVIRONMENTAL yrpnr,TH DIVISION AUG 3 ) tui I`{I <br /> SITE MITIGATION MASTMFTLE RECORD FORD J t <br /> ENVIRONPOENT HEALTH 2�1Q <br /> PERMIT/SERAQUINONME OU <br /> �RN y <br /> GENERAL 1PROGRAM FILE: New Change Edic HEATH 1E��T1U� <br /> ///��� (PROG4) revise /28 <br /> FACILITY ID 4D.b 2 D G� FACILITY PiAtC w � (/At Ay <br /> RECOFDI ID # `/ `/, 2 ` pQTOR DIST # - /_PRIOR SWEEP <br /> A <br /> £eeiMitigation: ✓Environmental AssessmentST/CAP cal Hazardous Wasee Invest zMat Pipeline Invest <br /> the= Lead Agency Sire ency: 1AQC9 DT5C EPA �ir- �ater Quality Site they Type Sice <br /> i <br /> DBSIGNATEb EMELOYEE 4 -/ / PROGRAM ELEMENT CURRENT STATUS <br /> / <br /> NUMEER OF UNITS EPA ID 0! INSPECTION CODE <br /> t <br /> Number of TANKS linked to rhia PROGRAM record ; <br /> (/BILLING ACIKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-END hourly charges associated with chis facility or activity will be billed to the party identified as the QILLING pAR'_y on <br /> the Masterfilc Record ,information Form. . <br /> I also certify that I have prepared this a8Plication and that the work to be Performed dill be done in accordance with all SAN <br /> JOAQ07N COUNZY Ordinance Ccdos and Standards, Srate and Federal laws. <br /> APPLICAMr'IS SIGNATURE., ; <br /> Title! ✓' 4 C"Y)� e� Dace: J/ <br /> i <br /> A — <br /> ADTMORIZATiION TO RELEASE INFORMATION: rn addition to the above, when applicable, T, the owner, operator or agent of same, of <br /> the property located at the above site address herehy authorize the release of any and all results, geotechnical darn and/or <br /> environmen[al/oite assessment information to SAN JOAQUW COUNTY PIMLIC EEALTH SERVICES MWIRON1,1ENTAL 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 /> Pee Amount Amount Paid Date of.Payment Paymeac Type Receipt 9 Check I Racy! Jay <br />