Laserfiche WebLink
L'0-08-1996 10:d9AM FROND P_ 2 <br /> SAN TOAQUIN COUNTY PUBLIC HEALTIA SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: Neuy/ Change Edit (PROG4) revised 5/23/54 <br /> FACILITY ID z /J�(U cACILITY NAME UA,1 ly <br /> RECORD ID # / PRIOR DIST # P IOR ZWEEPS # <br /> ice Mitigation: nvironmental Assessment ST/CAP 140cal Hazardous W&Zte Invest �azMac Pipeline Invest <br /> Cher Lead Agency Site gency: IRWQCB DT-SC aPA �Pl, Site �atcr Quality Site Cher Type Sic- <br /> DESIGNATED EMPLOYEE FROGRAM ELEMEISF # CURRENT STATUS <br /> NJMSER OF UNITS EPA ID #: INSPECTION CODE _ <br /> Number of TAN7,S linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge chat all Sita and/or pro;ee-_ sneciEic <br /> pHS-ZHD hourly charges associated with this Facility or activity will be billed to the party identified as chc SILLING PARTY on <br /> the Mastcrtilc Record Information Form. <br /> i also certify chat I have prepared this %pplicdtion and that the work cc be performed will be done in accordance :pit all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws_ <br /> APPLICAN'T'S SIGNATURE <br /> i Q q/ <br /> 7it1G:_ Date: le- V �74 <br /> AUTHORIZATION TO RELEAyE INFORMATIONi In addition to the above, when applicable. I, the owner, operator or agent of game, of <br /> the property located at the above nice address hereby authorize the release of any and all results, geQQTchnical iata and/or <br /> environmental/site allSC33merLt information to SAN 301QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it in available and at the same time it is provided to me or my =9reSentative. <br /> OEADLINE DATES: Inspection: Currcnt / ! Prior <br /> FCC Amount Amount Paid Date of Payment Payment Type Receipt # Check 4 Reevd By <br />