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r � � • • <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit n �/•�1 (PROG4) revised 5/23/54 <br /> FACILITY ID # D 11 11FACILITY NAME <br /> RECORD ID # n C ��� PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline invest <br /> Cher Lead Agency Site gency: WQCB DTSC EPA PL Site rater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM <br /> ELEMENT # V l '�V CURRENT STATUS <br /> NUMBER OF UNITS : EPA -D #: IINSPECTION CODE : <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: r, the undersigned owner, operator or agent of same, acknowledge chat all site and/or project specific <br /> PES-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: 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 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 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 /> �l�� <br /> 7/s-- N29le& C <br />