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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE� RECORD FORM <br /> r <br /> e� <br /> GENERAL PROGRAM FILE: New Change Edit (PRCG4) revised $/23/94 <br /> �h <br /> FACILITY ID # Q (�3 FACILITY NAME II <br /> I <br /> RECORD ID # r-0(.. t- PRIOR DIST # PRIOR SWEEPS #541� <br /> Site Mitigation: Environmental Assessment ST/CAP oca1 Hazardous Waste Invest a=-Yat Pipeline�Invest <br /> I� <br /> Cher Lead Agency SiteAgency-. �WQCB DTSC EPA PL Site ater Quality Sitether Type Site <br /> �p <br /> I <br /> I <br /> DESIGNATED EMPLOYEE # G[} PROGRAM ELEMENT # �// CURRENT STATUS j <br /> NUMBER OF UNITS �- [ l!EPA ID #: 0[�7 INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record WII <br /> III <br /> III <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent �f same, acknowledge that all site and/or project specific <br /> PFS-EBD 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. �I <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with a� .1 SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> I <br /> APPLICANT'S SIGNATURE : II <br /> Title: '"" +y l Y Dater t y ti <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when arplicable, I, the owner, operator or agent of ..ml of <br /> the property located at the above site address hereby authorize the release of any and all results, geotectaical 3ata and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALT=: DIVISION as Lon as <br /> i <br /> it is available and at the same time it is provided to me or my representative. <br /> I <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment YPe Receipt !# <br /> Check # Recvd By <br /> '&3L( 111,-(Li L4 u w <br /> I <br />