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 C' (PROG4) revised 5/23/94 <br /> FACILITY ID k OC FACILITY NAME <br /> RECORD ID kO ',( UL A Q S SJ PRIOR DIST k PRIOR SWEEPS k <br /> Site Mitigation: ironmental Assessment 1aST/CAP cal Hazardous Waste Invest -Mat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DISC EPA L Site -ter Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE k a1'� PROGRAM ELEMENT k ( ✓'v CURRENT STATUS <br /> NUMBER OF UNITS EPA ID k: INSPECTION CODE 300 <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 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 DMSION 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 k Check k Recvd 3y <br /> I LAI to 10 1 1S o y ,' <br />