Laserfiche WebLink
DESIGNATED EMPLOYEE 4 5 A I PROGRAM ELEMENT 4 CURRENT STATUS <br />NUMBER OF UNITS : EPA ID 4: INSPECTION CODE c.2 <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 No: Change <br /> <br />Edit <br /> <br />75 c,01, <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID 4 6. 0 0 Intl I FACILITY NAME <br />— el' vv-1"`r hi aitiviaNAT" 6 ,1-4., t $ <br />te ,... 2 <br />t 5 5 "rt <br />RECORD ID 4 0.4) S—g4G, PRIOR 01ST 4 PRIOR SWEEPS 4 <br />Site Mitigation: Environmental Assessment UST/CAP Local Hazardous Waste Invest RazMat Pipeline Invest <br />Other Lead Agency Site Agency: RWQCB DTSC EPA gPL Site Water Quality Site <br />._ <br />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 By <br />1/17.10 '-7 '73 (. 2-X-- <br />LIA0( 07 <br />Liu /514110