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NUMBER OF UNITS : EPA ID 4: INSPECTION :ODE : <br />Number of TANKS linked to this PROGRAM record <br /> <br />1c' 2 W PROGRAM ELEMENT 4 CURRENT STATUS DESIGNATED EMPLOYEE 4 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New Change <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID 4 64-DO 1 st SI FACILITY NAME S /tr\ IAA l -ea 1- SckA SPA`A -c-k <br />RECORD ID 4 !°/2 52-2_-C q 7 PRIOR 01ST 4 PRIOR SWEEPS 4 <br />z ockf, 5- Y\AcklAA S f- itv\G‘AAA-ccr, <br />Site Mitigation: Environmental Assessment UST/CAP Local Hazardous Waste Invest 4azMat Pipeline invest <br />her Lead Agency Site Agency: 1/4WQCB DISC EPA IPL Site Water Quality Site Other Type Site <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 />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, 1, 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 />DEADLINE DATES: Inspection: Current / / Prior / <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check 4 Recvd By <br />it a -f1.00 uH03 L.,-/ (13.5 +- <br />119 3 Li If <br />///2/6 3.