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<br />DESIGNATED EMPLOYEE # <br /> <br />5E3 E <br /> <br />PROGRAM ELEMENT # -2150 CURRENT STATUS <br /> <br />NUMBER OF UNITS : EPA ID 4: 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 P Change Edit (PROG4) revised 5/23/94 <br /> <br />FACILITY ID 4 (:- A- o o V'I 16 'a- FACILITY NAME AM Ee_ eortin-l-rN e-.-,,, <br />RECORD ID 4 ? Q\ fos_. PRIOR DIST 4 PRIOR SWEEPS 4 <br />Site Mitigation: p/Environmental Assessment UST/CAP Local Hazardous Waste Invest HazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DTSC EPA NPL Site Water Quality Site Other Type Site <br />r-105,0 <br />SC — — I Z. QC 51,15t.t( pg.) <br />\- 3' <br />BILLING ACICIOWLEDGEMENT: :, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHSTEHD 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 wo5k to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards e and Federal laws. <br />APPLICANT'S SIGNATURE <br />Title: 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 4 Check 4 Recvd By <br />3 Poe6 43/6 0////,/08 cAucte„ 4 2gisi — <br />/ 2( -- <br />/61)3D0 <br />1-147Lf <br />ca.< prce,