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Post-It"brand fax transmittal memo 7671 #of pages ► <br /> To Z <br /> G' From <br /> SAN JOAQUIN COUNTY PUBLI CO L�d� �,. I � Co. ,�� <br /> ENVIRONMENTAL HEM Dept. (� ✓_al_/� <br /> Phone Fax# Fax #�,__ �/ � <br /> SITE MITIGATION MASTEF #GU(�—7f(J <br /> .J <br /> 1 <br /> 4&8 <br /> GENERAL PROGRAM FILE: New Q'ange /—Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # w/�o Q O FACILITY NAME _ P") <br /> ✓Lb/ <br /> RECORD ID # �'nl I�J�CJ�( PRIOR DIST # PRIOR' SWEEPS # 'J <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest �ztfat Pipeline Invest <br /> Other Lead Agency SiteAgency: DTSC EPA L Site �ater Quality Site [Ther Type Site <br /> DESIGNATED EMPLOYEE # PROGRAM ET•EZIENT # 2 / ✓/�— CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: / `7INSPECTION 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 /> J�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 4 Recvd By <br />