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<br />DESIGNATED EMPLOYEE <br /> <br />”7 <br /> <br />PROGRAM ELEMENT <br /> <br />CURRENT STATUS <br /> <br />NUMBER OF UNITS : EPA ID 4: INSPECTION CODE <br />Number of TANKS linked to this PROGRAM record : <br />DEADLINE DATES: Inspection: Current Prior <br />Fee Amount <br />4a-og <br />Amount Paid Date of Payment Payment Type Receipt * <br />UtA1 4- <br />114 qlg <br />Check It Recvd By <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: X/ Change Edit <br /> (PROG4) revised 5/23/94 <br />FACILITY ID It <br /> UT/ I V. / f Adi - <br />8,56 /,--,,A, ct FACILITY NAME f(--e s ert-Lo 1--it <br />RECORD ID It ?-zi)-b--- 1 PRIOR 01ST * PRIOR SWEEPS 4 <br />Site Mitigation: ><'Environmental Assessment UST/CAP Local Hazardous Waste Invest HazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DISC EPA gPL Site Water Quality Site Other Type Site <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />?HS-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 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 /> <br />Date: <br /> <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 />• <br />lo /2-c2W- O1rtfL 14-401/Stiv-11164ka- , (5 11.05 0 Votiiiyeker.rr