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10-07-1996 10:35AM FROM P_ 2 <br /> (\b ` -SAN JOAQUIN COUNTY PUBLIC HEALIV SERVICES <br /> ENvZRONNxNIAL KEALTH DIVISION <br /> SITE mr7iGATioN MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: Ncw_x—Change Fd?t (PROG4) revised 5/23/44 <br /> FACILITY ID # 73 p� c^ACILITY NAM <br /> RECORD ID ft /J /, s PRIOR DIST # PRICR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous waste Invest azMat Pipeline invest <br /> Cher Lead Agency Site eacy: �RWQCB DISC EPA PL Site Per duality Site they Type Sire <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT 3 0 �� lZ7RRFS�7 STATUS 7 C\ <br /> NUMBER OF WITS EPA ID #: L+ �J INSPECTION CODE : J W <br /> Number of TANKS linked to this PROCRAM record <br /> SILLM ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project cpcclfic <br /> PHS-EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLI.G 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 al_ SAN <br /> JOAQUIN CO(ZM Ordinance C s d St-/u�/d/a'/Irds. St and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: d r('r <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the amove site address hereby authorize the release of any and all results, geotechnical 3ata and/or <br /> environmental/sice 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 repYeseatJtive. <br /> DEADLINE VAT-13; Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Oaymcnt Payment Type Recript # Check 4 Recvd By <br /> -�rhoo �� �00 VZ� <br />