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 r- (PROG4) revised/ 5/23/94 <br /> FACILITY ID k O Q O �S FACILITY NAME S�•pt�C.f�'j�„ �CJUS/NS ✓{¢^JOYS <br /> RECORD ID N O 1 � PRIOR DIST 4 PRIOR SWEEPS k <br /> J oU l -z..i s�( 5• � f�o�o2m <br /> Site Mitigation: 'ronmental Assessment /CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> ther Lead Agency Site envy: WQCB DISC EPA L Site ater Quality Site Cher Type Site <br /> DESIGNATED EMPLOYEE N b Z� PROGRAM ELEMENT $ Z`t S U CURRENT STATUS <br /> NUMBER OF UNITS EPA ID q: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACXNOWLEDGEMENT: 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 representacive. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check k Recvd By <br />