Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: <br /> New Change Edit <br /> FACILITY NAME ,)£ 6,,eoo7- 5om r -03 <br /> FACILITY ID # 7ow <br /> PRIOR DIST # PRIOR SWEEPS # <br /> RECORD ID # <br /> ite Mitigation: <br /> nvironmental Assessment ST/CAPocalEPSite <br /> dous Waste Invest azMat Pipeline Invest <br /> WQCB DTSC EPA <br /> ater Quality Site Lther Type Site <br /> they Lead Agency Site gency: <br /> J� PROGRAM ELEMENT SENT STATUS <br /> FDESIGNATED EMPLOYEE #"I" <br /> v {{,. <br /> INSPECTION CODE <br /> UNITS EPA ID #: <br /> Number of TANKS linked to this PROGRAM record <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 applicati 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 /> Date: <br /> Title: <br /> d' <br /> pp operator or agent of same, of <br /> AUTHORIZATION O RELEASE INFORMATION: In addition to the above, when applicable,of a I, the owner, is geotechnical data and/or <br /> the propert located at the above site address hereby authorize the release of any and all results, <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> environmental/site assessment information to SAN <br /> it is available and at the same time it is provided to me or my representative. <br /> / Prior <br /> DEADLINE DATES: Inspection: Current / <br /> Fee Amount Amount Paid Date of Payment Payment a Receipt # Check # <br /> Recvd By <br /> E6 <br />