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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 # reiek- 0 0] (,,g--P-,' FACILITY NAME 16-4,4Cy )6elf/(PrY <br />PRIOR SWEEPS # <br />.5/LIZ-e4°1"j7---' <br />RECORD ID # p 0._0 ,s-,,, I f ;---K3 PRIOR 01ST # <br />Site Mitigation: r. Environmental Assessment /CAP Local Hazardous Waste Invest AazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DISC EPA gPL Site Water Quality Site Other Type Site <br />Sa) 7C, : •wz.. <br />3/5 <br />DESIGNATED EMPLOYEE It 016, 0/ PROGRAM ELEMENT # 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-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 work to be xf,Irmed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal 1 <br />APPLICANT'S SIGNATURE : <br />Title: Date: <br /> <br />AUTHORIZATION TO RELEASE ORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located 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: DATES: Inspection: Current / / Prior / / <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />.34-7 741 0 ii/ / z 57-9 <br />c, —,9 4-,R•14 <br />6(4oc-