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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 5/23/94 <br /> VnVLvN P,,+CIF-iC 2��cRoi`f) <br /> FACILITY ID # FACILITY NAME A d E f-©V1Q C NT FM F,4r-114,rX <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Z-��} tfC INS ST2EE7' <br /> L <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste invest -Mat Pipeline Invest <br /> other Lead Agency Site envy: �RWQCB DTSC L <br /> EPA L Site �ater Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # Z PROGRAM ELEMENT # 2 O 1 CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: r INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the .mdersigned 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 3ILL114G PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that I have prepared this application and chat 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: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �2F,�.o� ✓ OD`d t�-� <br />