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<br />DESIGNATED EMPLOYEE # <br /> <br />PROGRAM ELEMENT # CO CURRENT STATUS <br /> <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <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 Edit (PROG4) revised 5/23/94 <br />FACILITY ID # C-Ok 00 k SktV2"-. <br />FACILITY NAME <br />,,.--- <br />J / <br />RECORD ID # RECORD e (IN oSIlAb1 PRIOR DIST # <br />i <br />PRIOR SWEEPS # <br />Site Mitigation: Environmental Assessment UST/CAP Local Hazardous Waste Invest 4azMat 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 />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: <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 />DEADLINE DATES: Inspection: Current / / Prior / / <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd <br />. <br />By <br />') • (-9)/ <br />i.....- _..." ?J_.0 dirt/07 rre.__ ‘; j3-1_, 4- <br />if-i' <br /># 1919'1 C