Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> SITE MITIGATION M70TERFILE RECORD FORM <br /> (pROG4) revised 5/2I/94 <br /> GENERAL PROGRAM FILE: New Change Edit <br /> FACILITY H <br /> FACILITY ID # M!c �4{j <br /> PRIOR DIST # PRIOR SWEE <br /> RECORD ID # <br /> Ie <br /> ironmental Assessment ST/CAPal Hazardous Waste Invest xMat Pipeline Invest <br /> r Lead Agency Site envy: IR <br /> WQCB DISC EPA L Site at Quality Site er Type Site <br /> D�j7 PROGRAM 1:11242:11, # 2 1 J i.l CURRENT STATUS <br /> DESIGNATID EMPLOYEE # �{{// <br /> INSPECTION RIDE : <br /> NUMBER OF UNITS EPA ID #: <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 /> PNS-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 /> Date: <br /> Title: <br /> AUTHORIZATION TO RELEASE ORMATION: In addition to the above, when applicable, I, the owner, opezacoi or agent of same, of <br /> the property located a e above site addresa are <br /> authorize Ue release of any and all results, geotechnical data and/or <br /> environmental/site sessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available d at the same time it is provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current / <br /> / Prior <br /> Date of Pa t PaYmna[ Receipt # Check # Recri BY <br /> Fee Amount Amount Paid Y <br /> 26l•° Z�ol•°" I Z� :� I?rb <br />