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SAN JOAQUL'c COUNTY PUBLIC HEALTH SERVICES <br /> F,NVIRO1IIS2r1AL HEALTH DIVISION <br /> SITE MITIGATION MRS ERFILE RECORD FORM <br /> (pgOG4) revised 5/23/94 <br /> V Change�Edit�— <br /> G"c..`1F.RAI. PROGRAM FILE: New� <br /> FACILITY NAME ��•�' <br /> FACILITY ID # <br /> PRIOR DIST # PRIOR TKZ—EPS # <br /> RECORD ID # <br /> ite Mitigation: <br /> al Hazardous Haste Invest <br /> zHat Pipeline Invest <br /> �( ironmental Assessment /CAP <br /> f a[er Quality Site then Type Sic <br /> Site envy: <br /> WQCB DISC EPA L Site <br /> ther Lead Agency <br /> D O O CURR=`7; STATUS <br /> PROGRAM El--i <br /> DESIGNATED EMPLOYEE # <br /> LNSPECTION CODE <br /> EPA ID #: <br /> NUMBER OF UNITS <br /> ;cumber of TANKS linked co this PROGRAM record <br /> BILLL`cG AMVOWLEDGEMENT: I, the undersigned owner, <br /> operator or agent of same, acknowledge that all site and/or project specific <br /> p�_� hourly charges associated <br /> with this facility or activity will be billed to the party identified as the 9ILLING PAR on <br /> the Masterfile Record Information Form• with all SAN <br /> I also certify that I have prepared this application and that the work to be performed will be done i1 accordance <br /> State and Federal laws. <br /> JOAQUIN COMMinance Codes and Standards, <br /> NTY <br /> r <br /> APPLICA.tii'S SIGNATURE <br /> Date: <br /> Title: <br /> LNFORMATZON: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> authorize the release of any and all results, geotechnical data and/or <br /> ADTHORZZATION TO RELEASE <br /> site address hereby HEALTH DMSION as soon as <br /> the property located at the above �pL7IY PUBLIC HEALTH SERVICES EYVIRONMENTAL <br /> environmental/site assessment information tor�� �to me or my representative. <br /> it is available and at the same time it is p <br /> / Prior <br /> DEADLINE DATES: <br /> Inspection: Current —�� <br /> check # Recvd BY <br /> Fee Amount Amount Paid Payment of Payt payment 'Type Receipt # <br /> 2�• 2�-a• II l ���- <br />