Laserfiche WebLink
J• <br /> 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 # Q D) FACILITY NAME <br /> RECORD ID # 5�11'-1LG PRIOR DIST # PRIOR SWEEPS <br /> YGq�� <br /> Site Mitigation: nvironmental Assessment T/CAP cal Hazardous Waste Invest lia <br /> zMat Pipeline Invest <br /> ther Lead Agency SiteAgency: WQ® DTSC EPA L Site ater <br /> Quality Site the Type Sit^ <br /> DESIGNATED EMPLOYEE # D/•,� PROGRAM ELEMENT Q 1 CURRENT STATUS <br /> NUMBER OF UNITS ((� EPA ID #: 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 Fcr-. <br /> I also certify chat I have prepared this application and that theto bell performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Fed laws. <br /> ` <br /> 1 <br /> APPLICANT'S SIGNATURE : <br /> Title: Date: <br /> AUTHORIZATION TO Frr ASE 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 <br /> Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �Jt2��/�X �• /�L!• f G� Off'�• <br />