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0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change--A—Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # OJ J 3-5 FACILITY NAME / •A l - �M sv G <br /> RECORD ID # L! PRIOR DIST # ?RIC., SWEEPS # <br /> Site Mitigation: ironmental Assessment T/CAP .cal Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQ® DTSC EPA L Site ter Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # O/�Y PROGRAM ELEMENT # y9 �� CURRn= STATUS TvE <br /> NUMBER OF UNITS : V/ EPA ID #: INSPE^ION 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 pard 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 Federa S. <br /> 1 <br /> 1 <br /> /APPLICANT'S SIGNATURE a-� PAYMENI <br /> M7art'ia Bowman MAR 13 1997 <br /> ✓itle: Trustee in Bankruptcy Date: y <br /> SANJUAOUW COUNTY <br /> FnnII``//IIPPp(U(��BNA�L�IIC���N�HTTE�QAIILTTuHcc aSIET�RtLJV!IICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, thaYd .AY;'OP'�'aC6t`6i'- erav QJVJ5kQN 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: Trent / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />