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3 <br /> zAYMENT <br /> >IEGEIVE® <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A Q R 0 5 1996 <br /> ENVIRONMENTAL HEALTH DIVISION �[[ U <br /> SITE MITIGATION MASTERFILE RECORD FORM SAN 'I�'-,ALT COUNTYSERVICES PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION ; <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME ✓ S/t/ � I(�E� <br /> RECORD ID # PRIOR DIST # 1"l� !P`RIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment /CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency SiteAgency: I IRWQCB DTSC EPA L Site ater Quality SiteT the= Type Site <br /> DESIGNATED EMPLOYEE # ,J/ TPROGRAM ELEMENT # �� CURRENT STATUS ����f ✓� /�/�f�(f <br /> NUMBER OF UNITS v C! EPA ID #: INSPECTION CODE <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-MW hourly charges associated with this facility or activity willbebilled 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, State and Federal laws. {{ <br /> APPLICANT'S SIGNATURE <br /> k <br /> Title: f Irl? <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of q <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 TOAQUIN 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 /> M <br /> Z9-50I Z .ao 423J .5 16 OF <br /> fe D� <br />