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vwi <br /> PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> v xENVIRONMENTAL HEALTH DIVISION j <br /> SITE MITIGATION MASTERFILE RECORD FORM MAS' 1's 2003 <br /> SAN N COUNTY <br /> PUBLICCN�OiH SERVICES <br /> GENERAL PROGRAM FILE: New Change Edit I ENVIROFJi,p[nJTp1HEf,tTNrIViS10N <br /> I (PROG4) revised 5/23/94 <br /> FACILITY I❑ # �D � FACILITY NAME <br /> ii <br /> RECORD ID # <br /> �� PRIOR DIST # �I IPRIOR SWEEPS # <br /> .I <br /> I <br /> Site Mitigation: Environmental Assessment ST/CAP cal HazardousWaste Invest azMat Pipeline Invest <br /> If <br /> ther Lead Agency Sitegency: WQCB DISC EPA Lisite ater Quality Site then Type Site <br /> I' <br /> II I <br /> } I <br /> OE5IGNATED EMPIAYEE # Cf� PROGRAM ELEMENT # � S I'` CURRENT STATUS - <br /> 11 r , ! <br /> NUMBER OF UNITS EPA ID #: I INSPECTION CODE <br /> I <br /> II I <br /> Number of TANKS linked to this PROGRAM record <br /> ;I <br /> �I <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 he billed11ito thei�party identified as the BILLING PARTY on <br /> the Masterfile Record Information Farm. I� <br /> 'I I <br /> I also certify that I have prepared this application and that the work to be per formed II lwill be done in accordance with all SAN <br /> SOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> II <br /> APPLICANT'S SIGNATURE <br /> II <br /> I� I <br /> v TitleDate: V <br /> - II I <br /> II I <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicablel, I, ttie owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and fall results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> II I <br /> it is available and at the same time it is provided to me or my representative. 'I <br /> i <br /> a <br /> II I <br /> II <br /> DEADLINE DATES: Inspection: Current / / Prio ! / / <br /> I'I <br /> Fee Amount Amount Paid Date of Payment Payment Type tReceipJ Check # Recvd By <br /> iI <br /> I' <br />