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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> q Wx <br /> C <br /> GENERAL PROGRAM FILE: New Cha <br /> nge IV <br /> Edit F- <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # Q ^ O ^ <br /> `-+l ( Il FACZLISNAMWELLQ <br /> RECORD ID # PRIOR PRIOR SWEEPS # p } <br /> T <br /> ite Mitigation: <br /> nvironmental Assessment ST/CAP <br /> coal Hazardous Waste Invest <br /> azMat Pipeline Invest <br /> they Lead Agency Site <br /> gency: I kWQCB DISC EPA <br /> PL Site ater Quality Site ther <br /> Type Site <br /> DESIGNATED EMPLOYEE # ✓1 l� PROGRAM ELEMENT # <br /> I l /� <br /> 12��t/ CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: JJ�� TT <br /> INSPECTION CODE (J v <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all <br /> PHS-EHD hourly charges associated with this facility or activity will site and/or project specific <br /> the Masterfile Record Information Form. be billed to the party identified as the BILLING PARTY on <br /> specific <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: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, _r, 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 <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type ype Aeceip[ # Check # Aecvd Ey <br /> � a� Z �X o--O � 3a �ooaso <br />