Laserfiche WebLink
T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> • SITE MITIGATION MASTERFrLE RECORD FORM <br /> GENERAL ?ROG?l.Y F_L'c: New <br /> Change Edit <br /> rA �Sa99 (PROG4) revised <br /> FACILITY NAME 5/23/94 <br /> 7 -7 ? PRIOR DIST q <br /> PRIOR SWEEPS 4 <br /> its Mitigation: imnment al Assessment ST/CAP <br /> cal Hazardous Waste Invest <br /> Cher Lead azMat Pipeline Invese <br /> Agency Site envy: WQC9 <br /> DTSC EPA L Site <br /> a[er Quality Site <br /> Cher Type Site <br /> ffofTANKS <br /> { <br /> PROGRAM EL'7�¢TiT g 1 fr1. CURRENT STATUS <br /> �! <br /> EPA ID 9: <br /> INSPECTION CODE <br /> to this PROGRAM record <br /> ' <br /> BILLING ACKNOWLEDGEMENT; I, the undersigned owner, operator or agent of same, acknowledge that all site and/or nroj ec[ specific <br /> pH8-� hourly charges associated with <br /> this facility or activity will be billed to the party identified as the BILLING PARTY the Masterfile Record information Form. <br /> ARTY on <br /> I also certify that I have prepared this application and that the <br /> work to be performed will be done in accordance with all <br /> fcllg COUNTY Ordinance Codes and Standards, State and Federal Laws. SAN <br /> 'PLICANT,SA,�SIGNATURE <br /> le: /Y L/y✓ <br /> Date: <br /> >RIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, <br /> roperty located at the easofan I, the owner, operator or agent of same, of <br /> above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> )nmental/site assessment information to <br /> SAN ed to m COUNTY PUBLICrepresentative. <br /> HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> available and at the same time it is provided Go me or my representative. <br /> E DATES: Inspection: �D D <br /> LLrtent / / <br /> Prior <br /> mount Amount Paid <br /> Date of Payment Payment Type Receipt q Check p <br /> � Recvd By <br /> 0y Com- 13S 1"e- <br />