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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y_. ENVIRONMENTAL HEALTH DIVISION r6. SITE MITIGATION MASTERFILE RECORD FORM rGENERAL PROGRAM FILE: Newer Change Edit fPROG4} revised 5/23/99 a FACILITY ID # FACILITY NAME is t RECORD ID # PRIOR DIST # PRIOR SWEEPS # ite Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest 4F` ther Lead Agency Sitd gency: W¢C8 DTSC EPA PL Site ater Quality Site Cher Type Site :t DESIGNATED EMPLOYEE PROGRAM ELEMENT # O CURRENT STATUS :Z NUMBER OF UNITS : EPA ID #: INSPECTION CODE .e 'rk' - - - - Number of TANKS linked to this PROGRAM record a "> BILLING ACXNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific Y i PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on i the Masterfile Record Information Form. "2 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN ! l�x JOAQUIN COUNTY Ordinance Codes and Standards; State and Federal laws. ; # Q� R;c . .APPLICANT'S SIGNATVR£ : aQA KGreve --- n�rJ : PAYMENT Title: 14r �!9 /_S� — Date: O f ~ �� - �+E IVSD. s �4+ �+ -_-- MAY 51997 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above,' when applicable; I, the owner, operator or agent of same, of y the property located at the above site address hereby authorize the release of any and all results�Saj og�cckr1' g aaNAO/or Z environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL,BHrAL44 "IIT.YSgtpVY�&ron as y ENVIRONMENTAL HEALTH DIVISION Pit is available and at the same time it is provided to me or my representative. DEADLINE DATESt Inspection: Current Prior Fee Amount Amount Paid' Date of Payment payment e.: Receipt # ,Check # ' ' Recvd By T21 Y s x ;