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Q�1�►,X IV►iLl`� ! <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C.EvvEU <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM F E g ],4 2000 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> GENERAL PROGRAM FILE: New i K—Change—Edit D 75—f-" ,(�yAROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME /" O Z"5 is <br /> RECORD ID # 1^ PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessmen T/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency Site gency: �RWQCB DTSC EPA L Site �ater Quality Site 10ther Type Site <br /> P '. <br /> DESIGNATED EMPLOYEE # �/�gy I <br /> AM PROGRELEMENT # Jrys/f CURRENT STATUS <br /> NUMBER OF UNITS lS/ EPA ID #: Gy 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-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 o be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Fed laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Z Date: <br /> AUTHORIZATION TO RELEASE /RMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at tte 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 /> tm11 pip 3G1 <br /> DEADLINE DATES: Inspection: Current / / Prior / / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd <br /> 24 3 23 2 zoo- <br />