Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM / <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # (�I�� ' FACILITY NAME <br /> RECORD ID # (Zo S a3 D� PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest �azMat Pipeline -Invest <br /> Other Lead Agency Site Agency: 1RWQC:B DISC EPA FPL <br /> ite ater Quality Site then Type Site <br /> r <br /> DESIGNATED EMPLOYEE # ( (' TPCURRENTROGRAM ELEMENT # STATUS <br /> NUMBER OF UNITS EPA ID #: w INSPECTION CODE \'• <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 /> 1 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. ENA <br /> SEG 1�lEC? <br /> APPLICANT'S SIGNATURE <br /> C <br /> �oAQv�N GOON r� <br /> Title: Date: SAN ONMENTAL <br /> ENVIR <br /> oexTo DEPARTMENT <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 /> xt ��lo s <br />