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j <br /> SAN JOAQUIN COUN'T'Y PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION u <br /> SITE MITIGATION MASrERFILE RECORD FORM �� <br /> CPN�°��j���NC,•;c.,af'` <br /> GENERAL PROGRAM FILE: New�_Change <br /> Edit (PRDG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME 1vflW`��� [/1� <br /> RECORD ID # �� PRIOR DIST # 7 PRIOR SWEEPS # <br /> Site Mitigation: ironmental Assessmen Local Hazardous Waste unrest ztiat Pipeline Irrvest <br /> other Lead'Agency Site enty: �WQCB <br /> DISC EPA L Sate ater Quality Site Ix lother Type Site <br /> ? 30.30 <br /> DESIGNATED EMPLOYEE <br /> Ta O4 <br /> PROGRAM ELEMENT # /3 D. 3 V CURRENT STATUS <br /> NUMBER OF UNITS ���LLLL EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record I ✓ �l b <br /> a that all site and/or project specific <br /> BILLING ACI4VOWLEDGEMEN'P: I, the undersigned owner, operator or agent of same, acknowledge <br /> FHS-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 /> 40 <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> °I <br /> APPLICANT'S SIGNATURE <br /> Date <br /> Title: <br /> AUTHORIZATION TO RELEASE INFO ION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the a site address hereby€authorize the release of any and all results, geotechnical data and/or <br /> environmental/site asses ent information to SAN .TOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and a 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 A Recvd By <br /> 2-1 q/0;� <br /> i <br />