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A07/28/2004 15:09 2094683 FIFTH FLOOR PAGE 02 SAN JOA000 COMM PQBL.IC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SITE MITIGATION MASMWR IX RECORD FORM OW AL PROGRAM F116; New._^Change Edit (PROG4) revised 5/23/94 FACILITX ID �} Cj FACILITY NAME RECORD ID 9 D ` S3 7j PRSOR DIST # lid PRIOR S41EEPS 4 Site Mitigation: &avironmental Assessment T/CAP Acal Hazardous Wagre Invest zMat Piceliee Invest Other Lead Agency SiteAgency: WQCS DISC BPA L Siteator )uality Site klcr Type Site DSSIQnM= EMPLOYEE # Gj PROGRAM ELFIN= # b CURRENT ;=TATUS NUMBER OF UNITS - ( EPA ID #: L �.7 IMPECT11,N CODE — Number 0E TANFCS linked to this PROGRAM record = BILLING Ar-XNCWLEDGffiMM; I, the undersigned owner, operarer or agent of same, acknowledge tha- all sire and/Ot prc.;ect specific PAS-EHD hourly charges associated wirh this facility or activity will be billed to the parry ilentified as the 2114,ING PARTY on the Masterfile Record Information Form. I Also certify that I have prepared this application and thac the work to he performed will be done in accordance ,ith all SAN JOAQUIN CQ= Ordinance Codes and standards, State and Federal laws. APPLICANT'S SIGNATURE. � — r Title- i1� Date,, ACTSHOR17ATION To REL AAE MFORMATION: In addition co the above, when applicable, I„ the owner, operator or ageAt it same, 0£ the property located at the above site addre9s hereby authorize Che release of any and all results. geotechnical dita and/or environmental/sitc aOsessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON ENTAL HEALTH DIVISION as soon as it is Available and at the same time it is provided to me or my representative. DEADLINE DATES: Ingpeetion= Cnrecne Fee Amounr Amouar Paid Date of Payment Payment Typc Receipt # Check # Rt-C-rd By r.