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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SITE MITIGATION MASTERFILE RECORD FORM Y GENERAL PROGRAM FILE: / New /� Change Edit (PROG4) revised 5/23/94 FACILITY ID # I �`�1 FACILITY NAME r/ RECORD ID # D(l/ q l ' / PRIOR DIST # PRIOR SWEEPS # Site Mitigation: nvironmental Assessment ST/CAP ocal Hazardous Waste Invest �azMat Pipeline Invest Other Lead Agency SiteAgency: I IRWQCB DTSC EPA L Site I �ater Quality Sitethey Type Site DESIGNATED EMPLOYEE # v/ PROGRAM ELEMENT # �U CURRENT STATUS NUMBER OF UNITS : ( EPA ID #: INSPECTION CODE Number of TANKS linked to this PROGRAM record BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on the Masterfile Record Information Form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. PAYM E N T RFCEE: IVr Q APPLICANT'S SIGNATURE MAY 2 V 1`7`1ry8 SAN JOAQUIN COUNTY VPUBLIC HEALTH SERVICES Title: Date: ENVIRONMENTAL HEALTH DIVISIOr" AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. DEADLINE DATES: Inspection: Current / / Prior Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By