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CURRENT STATUS PROGRAM ELEMENT # DESIGNATED EMPLOYEE 4 <br />3/6 <br />44° 3 /I- <br />3/5 <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 <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID 4 <br />A b 6 \ t 2 L\ <br />FACILITY NAME 295 6.70,444,e- ie6-6- <br />RECORD ID 4 'e Q\ o 5 '1 SO 1 (0 <br />PRIOR DIST # PRIOR SWEEPS 4 <br />Site Mitigation: Environmental Assessment <br />-> <br />T/CAP Local Hazardous Waste Invest 4azMat Pipeline Invest <br />3ther Lead Agency Site Agency: RWQCB1--- DTSC EPA gPL Site Water Quality Site Other Type Site <br />BILLING ACKNOWLEDGEMENT: :, 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 />e performed will be done in accordance with all SAN I also certify that I have prepared this application and that the wor <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Fede awe. <br />APPLICANT'S SIGNATURE <br />Title: <br />AUTHORIZATION TO RE 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 />Date: <br />when applicable, I, the owner, operator or agent of same, of <br />the release of any and all results, geocechnical data and/or <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />representative. <br />DEADLINE DATES: Inspection: Current / / Prior <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check 4 Recvd By <br />221744 <br />a/ 6 -2,5-os ..//// OW 56C7" Ciat <br />co\I\°c()