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f' 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised S/23/94 <br /> FACILITY ID k O j�� PACILITY NAME <br /> RECORD ID kv PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ironmental Assessment ST/CAP cal Hazardous Waste InvesC azMat Pipeline Imrest <br /> Other Lead Agency Site ency: WQCBDISC EPA L Site I ll-ter Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE PROGRAM ELEMENT 42 CURRENT STATUS g <br /> NUMBER OF UNITS EPA ID <br /> 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-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 accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Ae� Gate: <br /> AUTHORIZATION TO REX <br /> In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property locateaddress hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site on to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is availabl 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 # Recvd By <br /> z�7 267 g' �3 �SiS <br />