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Date: <br />Check # <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New V Change <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID 4 <br />RECORD ID 4 Pon-Je- 6-) <br />FACILITY FACILITY NAME <br />PRIOR DIST 4 PRIOR SWEEPS 4 <br />Site Mitigation: Environmental Assessment UST/ CAP Local Hazardous Waste Invest lazMat Pipeline Invest <br />RWQCB DTSC EPA Other Lead Agency Site Agency: NPL Site Aater Quality Site Other Type Site <br />PROGRAM ELEMENT 4 CURRENT STATUS <br />DESIGNATED EMPLOYEE 4 <br />NUMBER OF UNITS : EPA ID 4: INSPECTION 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 :his 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 />APPLICANT'S SIGNATURE : <br />Title: <br />n addition to the above, when applicable, I, the ownarOdp?rator or agent of same, of <br />the property located at the above / e address hereby authorize the release of any and all rofF4e4,'geotechnical data and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />it is available and at the saMe time it is provided to me or my representative. <br />SAN JOAQUIN COUN r <br />PUBLIC HEALTH SERVICES <br />:%IVIRONMENTAL HEALTH DIVIS' ' <br />DEADLINE DATES: Inspection: Current <br />AUTHORIZATION TO RELEASE INFORMATION: <br />as soon as <br />SE P 2 7 2032 <br />Prior <br />Receipt # <br />Fee Amount Amount Paid <br />71 2(e:7 <br />Date of Payment Payment Type <br />1//7"-' <br />Recvd By <br />ztC <br />3P/4---