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_ SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> A., - <br /> ENVM=VMML HEALTH DIVISION _ <br /> SITE MITIGATION MASTERFILE < t <br /> RECORD FORM�- <br /> V. <br /> i GENERAL PROGRAM FILE: �iewmange Fait .��,4. S: <br /> v sir (PROGO revised 5/23/94 <br /> FACILITY ID i FACILITY NAME <br /> RECORD ID #; S PRIOR DIST # rs SPRIOR SREEPS <br /> 1, ite Mitigatlon '' _ -' T <br /> >f tal ASHesament /CAP HazardouH Haste Invest <br /> _. .. n.•= r, Pipeline Invest <br /> k <br /> a �� .her Lead Agency Site' encs: - DTSC i EPA <br /> Site � . ater Quality Site er Type Site <br /> ; - <br /> DESIGNATED EMPLOYEE CRENZ <br /> NOMBER OF Mir. w £PA ID #: <br /> / PECSI <br /> ON CODE <br /> Number of TANKS linked to thin PROGRAM record <br /> BILLING I 'the �mdersigaed owner,. operator or agent of same &-)--1edge I <br /> edge that all site and/or project specific <br /> PHS_MM hourly charges asaociated.with this facilityor activity will be billed to the : <br /> y 'Pa identified as the BILLING PARTY on <br /> the Masterfile Record Inform Form. <br /> I also-cert'_iy that I have prepared this application and that the work to be <br /> performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. , <br /> t _ _ <br /> APPLICANT'S SIGNATURE - <br /> Title: ~ K+ <br /> Date: <br /> AUTHORIZATION TO strtracr INFORMATION: In addition to the above, when applicable, I, the owner, <br /> 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 COOZPTY PUBLIC HEALTH SERVICES ENV1R0NMEN�L 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: <br /> Inspection.'=•. .Current / <br /> / Prior <br /> Fee Amount]17 <br /> Paid ' Date of Payment Payment type Receipt # Check # Recvd By <br /> 'y �a <br />