SITE INFORMATION AND CORRESPONDENCE_CASE 1

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PAYMENT RECEIVED SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES MAR 17 2004 ENVIRONMENTAL HEALTH DIVISION SITE MITIGATION MASTERFILE RECORD FORM SANNCOUNTY ENVIRONMENTAL W HEALTH DEPARTMENT GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 FACILITY ID # 64 FACILITY NAME RECORD ID # R�5-a 3PRIOR DIST --— - -PRIOR Site Mitigation: Environmental Assessment ST/CAP Loca zar us as a Invest azMat Pipeline Invest then Lead Agency site envy: WQCB DTSC EPA L Site �ater Quality Site they Type Site DESIGNATED EMPLOYEE # Gi W ^f PROGRAM ELEMENT # / C/ r CURRENT STATUS NUMBER OF UNITS l EPA(ID #: C_ 1✓ INSPECTION CODE Number of TANKS linked to this PROGRAM record BILLING ACKNOWLEDGEMENT: I. the .`ndersigned owner, operator or agent of same, acknowledge that all site and/or project specific ?HS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on the Masterfile Record Information Form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. P�- I v -,A DEADLINE DATES: Inspection: Current / / Prior -/-/ Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By �-�q D �7- -Z111t