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FACILITY ID 4 <br />RECORD ID 4 <br />a9Ote,4,1-m10 <br />FACILITY NAME _ 7-2ser-tto <br /> <br />PRIOR DIST 4 <br /> <br />PRIOR SWEEPS 4 <br /> <br />INSPECTION CODE : <br />NUMBER OF UNITS EPA ID 4: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />-ENVIRONMLNTAL HEALTH DiyisIoN <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New Y Change Edit <br />(PROG4) revised 5/23/94 <br />Site Mitigation: <br />Environmental Assessment ST/CAP 1 Local Hazardous Waste Invest azMat Pipeline Invest <br />Other Lead Agency Site Agency: 1 iRWQCB1 DTSC I EPA PL Site L Site ater Quality Site Other Type Site <br />1 DESIGNATED EMPLOYEE 4 <br />PROGRAM ELEMENT # 1 <br />_ CURRENT STATUS <br /> <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 />?HS-EHD hourly <br />the Masterfile <br />I also certify <br />JOAQUIN COUNTY <br />APPLICANT'S SIGNATURE : <br />Title: <br />charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Record Information Form. <br />that I have prepared this application and <br />that the work to be performed will be done in accordance with all SAN <br />Ordinance Codes and Standards. State and Federal laws. <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, <br />the property located at the above site address hereby authorize <br />environmental/site assessment information to SAN JOAQUIN COUNTY <br />it is available and at the same time it is provided to me or my <br />when applicable. I, the owner, operator or agent of same, of <br />the release of any and all results, geotechnical data and/or <br />PUBLIC HEALTH SERVICES alVIRONMENTAL HEALTH DIVISION. as soon as <br />representative. <br />Prior <br />DEADLINE DATES: Inspection: Current <br />Recvd By <br />Fee Amount Amount Paid <br />d-6 <br />Date of Payment Payment Type <br />( <br />Receipt 4 Check <br />?/9 /J.#-