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SAN JOAQUIN COUNTY pUBLIC HEALTH SERVICES <br /> ENV1R0NMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change <br /> Edit <br /> FACILITY NAME <br /> FACILITY ID # <br /> PRIOR DIST # PRIOR SNEEPS # <br /> RECORD ID # �� a <br /> ite Mitigation: vironmental Assessment ST/CAP <br /> al Hazardous Waste Invest zMat Pipeline Invest <br /> envy: <br /> ther Type Site <br /> WQCB DISC EPA <br /> L Site ater Quali[y Site <br /> ther Lead Agency Site <br /> O(j PROGRAM ELEXENf # 2-9 CURR <br /> ENT STATUS <br /> FOESIG .PLOYEE # ((/ a / <br /> INSPECTION CODE <br /> TS : �� <br /> EPA ID #: <br /> lumber 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 Form. <br /> I also certify chat 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 /> ,J <br /> APPLICANT'S SIGNATURE <br /> Date <br /> Title: <br /> RMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> AUTHORIZATION TO RELEASE by Y geotechnical data and/or <br /> the property located at a above site address here authorize the release of anand all results, <br /> the property <br /> kite as essment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmit is available an at the same time it is provided to me or my representative. <br /> / / Prior <br /> DEADLINE DATES: Inspection: Current <br /> Recei t # Check # Recvd BY <br /> Fee Amount <br /> Amount Paid Date of Payment Payment Type P <br /> �► 1^�� /I 17r-2 - <br />