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w SII •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 /> FACILITY ID # (_ rtT \ Q FACILITY NAME <br /> RECORD ID # U U�V`2�l " PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest zMat,Pipeline Invest <br /> Other Lead Agency Site Agency: WQCS DISC EPA L Site ater Quality Site ther Type Site <br /> 3iD <br /> DESIGNATED EMPLOYEE # DV PROGRAM ELEMENT # �j9�6J CURRENT STATUS <br /> NUMBER OF UNITS VVV EPA ID #: INSPECTION CODE <br /> I <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 an ,Federa 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 Paymenta Receipt 4 Check # Recvd By <br />