Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG'4) revised 5/23/94 <br /> FACILITY ID # 1 FACILITY NAME /► V'\ <br /> RECORD ID # ( ��' PRIOR DIST # PRIOR SWEEPS # <br /> ,ite Mitigation: Environmental Assessment ST/CAP ocal Hazardous Waste Invest �azMat PipelJ.ne Invest <br /> ther Lead Agency Site gency: �WQCB DTSC EPA PL Site ater Quality Site they Type Site <br /> -F - <br /> DESIGNATED EMPLOYEE # R PROGRAM ELEMENT # 7 �O TCURRENT STATUS <br /> NUMBER OF UNITS : I EPA ID #: INSPECTION CODE <br /> :lumber 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 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 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 /> 6�-- b"VI <br /> DEADLINE DATES: Inspection: Current / / Prior -/-/- <br /> Fee <br /> /Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2,3(03 F7 to 0 � <br />