Laserfiche WebLink
�F <br /> SAN JCAQUIN COUNTY PUBLIC HEALTH SEERVICEES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM ?17,EE: New Change ^edit n y(PROG4) revised 5/23/54 <br /> FACILITY ID R (� O T Q �j FACILITY NAME //....• Y_ _ / �L f/ <br /> .RECORD ID # ` 11^ l J^ n T PRIOR DIST 6 ✓`� PRIOR//SWEEPS <br /> Kq/�- <br /> ice Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Gher Lead Agency Site / ency: WQCH DTSC :?A PL Site rater Quality Site then Type Site <br /> DESIGNATED EMPLOYEE d G+ ..PROGRAM ELEMENT # , l7.5-D <br /> . CURRENT STANS <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 Form. <br /> I also certify that I have prepared this application and chat 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 /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check 4 Recvd By <br />