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SAN JOAQUIN COUNTY PUBLIC SScALTR SERVICES <br /> ENVIRONMENTAL HENL A DMSION <br /> SITE MITIGATION MASTER°ILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New..change <br /> Edit <br /> FACILITY NAND <br /> FACILITY ID # <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # <br /> 1ZOOmentdl A59C94mCRt T/CAP <br /> al Hazardous Wasce Invest zMat Pipeline Invest <br /> ite Mitigation: <br /> envy: WQCB DISC <br /> EPA L Site ater Quality Site ther Type Site <br /> they Lead Agency Site <br /> PROGRAM ELEMENT # ?j(�5 U CORGFNf STATUS <br /> DESIGNATED FSfPLOYEE # �(P SSS��1 <br /> INSPECTION CODE <br /> NUMBER OF UNITS : <br /> EPA ID #: <br /> Number aF TANKS liiJced to this PROGRAM record <br /> operator or agent of sane, acknowledge that all site and/or project specific <br /> BILLING AC[GJOWL"9(SEMENT: I, the undersigned owner, <br /> ified as the BILLING PARTY on <br /> PHS-EMD hourly charges associated with this facility Or activity will be billed to the party ident <br /> the Masterfile Record Information Fotm. <br /> I also certify that I have prepared this application and that the work Co erfozmed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal la <br /> iJ <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE RMATION: In addition co the above, when applicable, I, the owner, operator or agent of same, of <br /> CE <br /> the property located the above site address hereby authorize � Oleo f anSERy aENVIRONMENTAL eHEouTTR.MSIONesl aas soon as <br /> e[rvimRmencal/site ssessment :,if <br /> to SAN JOAQDIN representative <br /> it is available d at the same time it is provided to me or my p <br /> Prior <br /> DEADLINE DATES: Inspectioo: Current <br /> payment type Receipt # Check # Recvd By <br /> Fee Amount <br /> Amount Paid .Dace of Payment Vw�� <br />