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SAN JOAQUIN COUNTY PUBLIC _,ALTH SERVICES <br /> ENV=RONMENIAL rEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM -_LE: New__XL_Change Edit i-ROG4) revised 5/23/95 <br /> AGILITY iD xE: FACILITY NAME Tr, v V- <br /> RECORD ID n PRIOR DIST ;# PRIOR SWEEPS <br /> te Mitigation: Environmental Assessment ST/CAP :,ocal Hazardous caste Invest �az.Mat Pipeline invest <br /> Atner Lead Agency Site ency: X� W C3 I �L �azer - 10ther '^pe Site <br /> 9 g Q DTSC EPA Si`e Qual'ty Site _ <br /> _——DESIGNATED EMPLOYEE n PROGRAM ELEMx' f # �2(� CURRENT STATUS <br /> I ' <br /> ?TUMBER OF UNITS : EPA ID #. --NSPECTION CODE Q <br /> ,lumber of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: the undersigned owner, operator or agent of same, acknowledge that ail site and/or project specific <br /> ?PS-E:-M hourly charges associated with this facility or activity will be billed to the party identified as the BILLING ?ARTY on <br /> the Masterfile Record Informacicn ?orm. <br /> 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 =odes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNAT-URE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE --1T ORMATION: 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 HEALIT SERVICES ENVIRONMENTAL ;"E.ALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> DEADLINE DATES: =nspection: __-cent <br /> :__ ."mount Amount ?aid I Date of Pavment I Pay ent �e i Rece;pt - I :heck # Recvd By <br /> 41716 I z-73u� <br />