Laserfiche WebLink
• SAN JOAQUIN COMM PUBLIC!HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFIL6 [LECOAD F0 <br /> GENERAL PROGRAM FILE: ^New Change Edie (PROG4) revised 5/23/94 <br /> FACILITY ID FACILITY NAME <br /> RECORD ID # 4 VVV PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: ix�—xvnmental Assessment /CAP al Hazardous Waste Inrcsc -Kat Pipeline Invesc <br /> Cher Lead Agency Site ency: I WQCB DISC EPA Site -ter Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # O 7 PROGRAM ELEMENT # 9 5-17 CURRENT STATUS <br /> NUMBER OF UNITS : EPA IO #: INSPECTION CODE 316 h 3 I D <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 the= 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 CDC= 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 rapmsmtative. <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Remd By <br />