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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New_)�_Change Edit �) iPROG4) revised 5/23/94 <br /> FACILITY iD # FACILITY NAME Tri rx V- ( c .4 tJQ <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS <br /> Sire Mitigation: Environmental Assessment ST/CAP Local Hazardous haste Invest azMat Pipeline Invest <br /> other Lead Agency SiteAgency: WQCB DTSC EPA L Site Faer Quality Site ther :ype Site <br /> DESIGNATED EMPLOYEE # 7 <br /> ROGRAM ELEMENT # a b CURRENT STATUS <br /> P <br /> NUMBER OF UNITS ` EPA ID #: INSPECTION CODE Q U <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 Informat'_on 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 ,mount Paid Date of Payment Payment Type Receipt 4 Check 4 Recvd By <br />