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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM R <br /> GENERAL PROGRAM FILE: NewwChange Edit W <br /> (PROGa) revised 5/23/99 <br /> FACILITY ID # Fft o I ko q-3 FACILITY NAME V 1 / It) <br /> I ti <br /> RECORD TO # �Pko5a382�a- PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment T/CAP al Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site envy: QCB DfSC EPA L Site ater <br /> Quality Site Chez Type Site <br /> DESIGNATED EMPLOYEE # ✓/ / PROGRAM ELEMENT # aq�S CURRENT STATUS <br /> NUMBER OF UNITS : {{EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS-END 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 /> -TA) -7 s-7 <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # deck # Recvd By <br /> ?g �a7e2- 7 . <br />