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07/19/2001 09: 30 2094683433 FIFTH FLOOR PAGE 02 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTEYFILE RECORD :ORM <br /> GENERAL PRC*RAM FII,Et NcwC21angcs Edit (1?R[K;4) revised 5/23/94 <br /> �[ FACILITY Ib d {}— /33 / (� FACILITY NAME <br /> 1` RECORD ID 4 /� � 7,3 q'2 <br /> PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Ravirmnmenral Assessment ST/CAP cal Razardous blasts Invest azMat Pipeline Invest <br /> Cher Lead Agency Site RWQCS DISC EPA L <br /> Sita ater Quality Site cher type Site <br /> DESIMrATED ZMPLOYSE # 7 PROGRAM ELEIENT # Q e) CUR-RENT STATUS <br /> NUMBER OF OdTTS EPA ZD M: [ INSPECTION CODE <br /> Ifumber of TANKS linked to this FROM M record <br /> BIL:,ING ACXNUWL5:DGEMENT: I, the undersigned owner, operator or agent of same., acknowledge that all site and/or project specific <br /> PHs-Epa) hourly chargez associated with chis facility or activity will be billed to the party identified as the BILLING PARTY on <br /> the mastertile Record III�ermACiCn Form_ <br /> I also certify that Z 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 SIGNATURB <br /> ` <br /> Title!, _ 7,t � L h`'C ( c 4 5/ Date.. Z?- <br /> ALrHORIZATTON <br /> TO RELEASE rNBORMATICN: 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 rejdase of any And all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOACUIN COUNTY FOBLIC HEALTH SERVICES ENVIRONMENTAL VXALTH DIVISION as soon as <br /> it is available and at the same t m& it is provided c0 me or my representative, <br /> 7,civ oo��a�9 <br /> DEADLINE DATES: Inspection: Current / / ?rior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt Y Check 0 Rle,c--d By <br />