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4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES pAY NIE <br /> NT <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> SITE MITIGATION MASTERFILE RECORD FORM AUG 2 $ 2006 <br /> SAN JOAQUIN OOUNTY <br /> ENVIRONMENTAL <br /> GENERAL PROGRAM FILE: New 111 <br /> Change Edit 1911'zehpTd <br /> e 5/23/94 <br /> FACILITY ID # (/V O / !f� FACILITY NAME l "tSy} �S <br /> �rrr 1111 7( Q� - <br /> RECORD ID # P�s 4 3 PRIOR DIST # PRIJ SWEEPS # <br /> Site Mitigation: ✓ Environmental Assessment k <br /> T/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> [her Lead Agency Site Agency: 1RWQCB DISC EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # 9 1 7 PROGRAM ELEMENT # d- CURRENT STATUS <br /> NUMBER OF UNITS : ` EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, 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 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 /> Zrvt <br /> ob !v f zry Z$ <br />