Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
• 0 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit /J /(PROG41) revised 5/23/94 <br /> FACILITY ID # ® I FACILITY NAME <br /> RECORD ID # U'G ^ I�D PRIOR DIST # / PRIOR SWEEPS # J <br /> Site Mitigacion: X ironmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQCB UTSC EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE # C� PROGRAM ELEMENT # 7 5(� CURRENT STATUS <br /> NUMBER OF UNITS : ��(++ EPA ID #: �+ INSPECTION CODE <br /> Number of TANIGS linked to this PROGRAM record J(0_ 3 ' C) <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge chat 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 an <br /> the Masterfile Record Information Form. <br /> I also certify chat 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 RE181 ZERMATION: 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 /> envirtnmental/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 /> 1075-S <br />