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0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROSO revised 5/23/94 <br /> FACILITY ID # O D T Z-- — I I <br /> FACILITY NAME "`l✓l, �� � y��C �e'tel�ld�L J- <br /> RECORD ID # FR 5 (,,z 0 3 1 <br /> PRIOR DIST # "` PRIOR SWEEPS #`.J <br /> Site Mitigation: vironmental Assessment SVCAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency Site ency: WQCB DISC EPA PL Site ater Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # D 2� PROGRAM ELEMENT # L /_ Q CURRENT STATUS 1r Q <br /> NUMBER OF UNITS ELLLLPA ID #: oG Z `P INSPECTION CODE V V <br /> Number of TANKS linked to this PROGRAM record <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 Farm. <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 /> APPLICANT'S SIGNATURE : <br /> J Title: Date: <br /> N 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />