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02 5 DESIGNATED EMPLOYEE # PROGRAM ELEMENT # CURRENT STATUS <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : e:1--O <br />Number of TANKS linked to this PROGRAM record : <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New Change <br /> <br />Edit <br /> <br />[ $O <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID # -(-',A 0 0 i LLD,c--- FACILITY NAME -- Mit...je.A., Gee) U/ e Tits (-4-5± <br />RECORD ID # pp__ co-91__-,s PRIOR 01ST # PRIOR SWEEPS # <br />Site Mitigation: Environmental Assessment UST/CAP Local Hazardous Waste Invest 4azMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DTSC EPA \IPL Site dater 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 />PHS-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: Date: <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 />DEADLINE DATES: Inspection: Current / / Prior / / <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />t,./11 tke2:1q - t‘12/t(0 l...--" &,--i -5711 2_ i,,,e___ <br />ilt/o.S- <br />1/nni lt 0-11