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GENERAL PROGRAM FILE: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />New Change v Edit <br />(PROG4) revised 5/23/94 <br />FACILITY ZD # <br />66 G y <br />FACILITY NAME <br />Environmental Assessment <br />RECORD ID # <br />5,c 5--? (/} 3 <br />PRIOR DIST # <br />Recvd By <br />PRIOR SWEEPS # <br />X60 ss <br />DESIGNATED EMPLOYEE # l r -] <br />PROGRAM ELEMENT # �O CURRENT STATUS pp�� <br />NUMBER OF UNITS EPA ID #: INSPECTION CODE V <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 performed will be done in accord e with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />� l <br />OCT 10 1995 <br />APPLICANT'S SIGNATURE <br />SAN JOAQUIIN CUUiN l ) <br />PUBLIC HEALTH SERVICES <br />Title' C oc- Date: � 0 � � 1 ENVIRONMENTAL HEALTH DIVISION <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 />DEADLINE DATES: Inspection: Current / / Prior / / <br />Site Mitigation: <br />Amount Paid <br />Environmental Assessment <br />ST/CAP <br />Receipt # <br />ocal Hazardous Waste Invest <br />­—T— <br />Recvd By <br />�azMat Pipeline Invest <br />Other Lead Agency SiteAgency: <br />e. — <br />30 <br />IRWQCB <br />DTSC <br />EPA <br />PL Site <br />Tter <br />Quality Site <br />1 <br />they Type Site <br />10 <br />X60 ss <br />DESIGNATED EMPLOYEE # l r -] <br />PROGRAM ELEMENT # �O CURRENT STATUS pp�� <br />NUMBER OF UNITS EPA ID #: INSPECTION CODE V <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 performed will be done in accord e with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />� l <br />OCT 10 1995 <br />APPLICANT'S SIGNATURE <br />SAN JOAQUIIN CUUiN l ) <br />PUBLIC HEALTH SERVICES <br />Title' C oc- Date: � 0 � � 1 ENVIRONMENTAL HEALTH DIVISION <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 />DEADLINE DATES: Inspection: Current / / Prior / / <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />� <br />, , �s <br />e. — <br />30 <br />