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DESIGNATED EMPLOYEE # SY') PROGRAM ELEMENT # 011: o CURRENT STATUS <br />NUMBER OF UNITS : EPA ID #: <br /> <br />INSPECTION CODE : <br /> <br />Number of TANKS linked to this PROGRAM record : <br /> <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: 4//// New Change <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID # <br />€.CN r3 0 ic\ntrA FACILITY NAME , to <br />1 vIkakt_e_e.,_., <br />RECORD ID # C QI b 5022 1 59 PRIOR 01ST # <br />, <br />PRIOR SWEEPS # <br />Site Mitigation: Environmental Assessment UST/CAP ..,ocal Hazardous Waste Invest RazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DTSC EPA NPL 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 />PRS-E103 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 />,4171( I g41(2;Lf