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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New <br /> Change Edit <br /> (PROG41 revised 5/23/94 <br /> FACILITY ID # <br /> PACILITY NAME /. i �_ <br /> RECORD ID # �O �OOO W <br /> TI O��"'Z PRIOR DISE # PRIOR SWEEPS # <br /> P�asl6s�8a <br /> ite Mitigation: iroOne,ntal Assessment <br /> T/CAP cal Hazardous Waste Invest <br /> zMat Pipeline Illveat <br /> that Lead Agency Site ency: WQ® <br /> DISC EPA L Site star Quality Site Cher <br /> Type Site <br /> =TANKS <br /> b 19 PROGRAM ELEMENT # ^Rr� <br /> l'W CURRENT STATUS <br /> EPA ID <br /> INSPECTION CODE <br /> 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 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 /> Title; <br /> Date: <br /> 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 <br /> 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 DMSION 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 / / <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Rem By <br /> �(26(.od -9 ZO-00 U(z�loo <br />