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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> I ( Sr Z I uJ CISH <br /> GENERAL PROGRAM FILE: � <br /> '/� NewChange Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # u O O ` 4 110 FACILITY NAhffi ��,�,• wa.�yr C l�'�'`( (/�_ <br /> RECORD ID # O Cv Z 3 PRIOR DIST # •"v` PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Ile <br /> cal Hazardous Waste Invest azmat Pipeline Invest <br /> Other Lead Agency Site ency: WQCB DTSC EPA PL Site _ter Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # iYJ/ PROGRAM ELEMENT # 5-PCURRENT 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-KED 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 /> s <br /> I 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, 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 Amount Paid Date of Payment Payment Type Receipt # Check # Recd By <br />