Laserfiche WebLink
i <br /> ♦ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> j SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New • Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # Cn� 66 �G� II FACILITY NAME 7- <br /> RECORD ID # /� /3� PRIOR DIST # PRIOR SWEEPS # <br /> P Q� ©52"A2k Ct <br /> ite Mitigation: Y vironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency Site 9en7 <br /> WQCB DTSC EPA L Site ater Quality Site Cher Type Site <br /> �f0 <br /> 315 <br /> DESIGNATED EMPLOYEE Tp 6 PROGRAM ELEMENT # 2.4 (} CURRENT STATUS <br /> NUMBER OF UNITS EPA ED #: - INSPECTION CODE <br /> I <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 /> PRS' 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 Forma <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 R�I.EA.S2 ORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located 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 # Cieck # Recvd By <br /> 3 sa 1-Z9-a 9 3aa � <br /> s � <br />