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DESIGNATED EMPLOYEE 4 <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <br />Number of TANKS linked to this PROGRAM record : <br /> <br />CURRENT STATUS <br />'bit? vi 95 <br />PROGRAM ELEMENT # <br /> <br />APPLICANT'S SIGNATURE <br />Title: <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New y Change <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID 4 M 0 O i c4) i FACILITY NAME Zedt' itelt0e( seze_64e5.1( <br />RECORD ID 4 fro s-v-3 t( -7 q PRIOR 01ST # PRIOR SWEEPS # <br />Site Mitigation: %.4,Environmental Assessment UST Local Hazardous Waste Invest HazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DTSC EPA APL Site 'lacer 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 />P!45-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 a ederal laws. <br />Date: <br />AUTHORIZATION TO RE E INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property loc ed at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br />environmenta 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 />INU.DO /77 <br />DEADLINE DATES: Inspection: Current / / Prior / / <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check 4 Recvd By <br />'2,0110/ 2.'VII i'-. C— 5 ....,'" 7((q f I)