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?yy SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION ' <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> " GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME <br /> .I - V <br /> VV <br /> S <br /> ' RECORDID # PRIOR DIST # PRIOR SWEEPS # <br /> 'N•g <br /> lY;e <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> ah' they Lead A <br /> _y genc y SiteAgency: WQCB DTSC EPA PL Site stet Quality Site they Type Site <br /> R, <br /> f*Ea. <br /> il. <br /> AA <br /> �3 DESIGNATED EMPLOYEE # / PROGRAM ELEMENT # 9,S� CURRENT STATUS <br /> r NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> !R- <br /> Number of TANKS linked to this PROGRAM record , <br /> 2 <br /> s: <br /> ¢;BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, Acknowledge that all site and/or project specific <br /> Z; 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 /> k'JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> SF <br /> ZJ)yAPPLICANT'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 /> t the property located at the above site address hereby authorize the release o y and\allresu Its, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLITH SERVICES ERVIRONMENTAL H TH DIVISION as soon as <br /> E;. <br /> it is available and at the same time it is provided to me or my rep ee ntative. <br /> Tw o q�o�s <br /> DEADLINE DATES: Inspection: Current / / Prior / <br /> Fee Amount Amount Paid Date of Payment . Payment Type Receipt 4 Check 4 Recvd By <br />