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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3�^ SITE MITIGATION MASTERFILE RECORD FORM lUJ1YG giTE GENERAL PROGRAM FILE: New Change Edit (PROG41 revised E/23/34 FACILITY ID # v 0/a 6o FACILITY NAME RECORD ID 4 PRIOR DIST d PRIOR SWEEPS # Site Mitigation: nvironmental Assessment T/CAP al Hazardous Waste Invest zMat Pipeline Invest Cher Lead Agency Site envy: WQCB OTSC EPA PL Site -ter Quality Site I 10ther Type Site 2-`1 'G6 DESIGNATED EMPLOYEE k —�. 1^`q PROGRAM ELEMENT p CURRENT STATUS NUMBER OF UNITS : ill 1 l EPA ID 4: !NSPECTION CODE Number of TANKS linked to this PROGRAM record BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on the Masterfile Record information Form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and St rds, rateand Federal Laws. ��,s` r`il�)./ �'+J_ A ® APPLICANT'S SIGNATURE : SQA v"A V `7-I"'t'� IST v�'t-ANE Ch.Stn Title: �t Cp �' - J ' Date: �a`N b. ZDV AITTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. DEADLINE DATES: Inspection: Current / / Prior Fee Amount Amount Paid Date of Payment Payment Type Receipt 9 Check 4 Rscvd By 234 �'a3� - � il/- � ✓ X370 �