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SAN JOAQVIN ODUNTY PUBLIC 1-AL:'H SERVICES <br /> EYVIROAMENIAL Hmr.1 DIVISIO. <br /> SITE MITIGATION MASTERFILE RECCE FORM <br /> AM FILE:' New C`ange Edi[ <br /> (PROG41 revised 5/23/94 <br /> G'-;ERAL PROGR <br /> FACILITY ID # FACILITY NAME <br /> RECORD ID # l�/} PRIOR DIST # PRIOR SWEEPS # <br /> JJ -+46 L I v . 1 7• G _ I--.. <br /> Ste Mitigation: anvironmental Assessment ST/CAP cal FazardOus waste Invest �­Mat Pipeline Invest <br /> —j Cher Lead Agency Site gency: wQC3 DISC -PA L Sita aver Quality Site10-.her Type <br /> DESIGNATED ZSPLCYEE # 5p L�1 p�CvRAM EL�^41T ' S O C[Tt7EI1 ST;. US <br /> r-0-M=R OF UNITS EPA ID #. INSPECTION CODE. <br /> Nur,lber of TANKS linked to this PROG'+AM record <br /> BILLING AC C*tOWLc`DG�""-NF: I, the undersigned owner, operator or agent of sane, acknowledge that all site anal/or project Specific <br /> rrS-ERM hourly charges associated with this facility or activity will be billed to the party identified as the BI=TING PARTY c: <br /> .::e Masterfile Record Irfcr:aation Fora. <br /> I also certify that I have prepared this application and that the work to be perfo—ed will be done in accordance with all SAN <br /> ZoAquIN COUNTY Ordinance Codes and Sta.^.dards, Sta d Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title:- ��n 1St` Daze: <br /> AUI4CRIZATION TO RELEASE INFORMATION: In addition to'the:above, when applicable, =, 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 /> enviro:smental/site assessment information to SAN JCAQUIN CCU-NT:' Pu?LIC !-=AL 4 SERVICES ENVIRON!-=.AL FSP.L-11A DIVISION as 53cn as <br /> it is available and at the same time it is provided to me or my representative. <br /> �yg70 <br /> DEADLINE DATES: Inspection: C=-:ent / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check 4 Recvd By <br />