Laserfiche WebLink
7 <br /> ._En. �► <br /> \TVIRONMEI,77a� FBAT.7B DrVISIO <br /> S'ITH :MITIGATIOr; `rtAST£nFTDE RECORD F5R_M <br /> GENER.0 PROGRAM' FILE: New YP Change C" Edit (nRCG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME /� / ! <br /> 02 G {ia <br /> RECORD ID # I PRIOR DIST ,", PRIOR SWEEPS n <br /> _ e Mitigation: Environmental. Assessment JST/CAP Deal Hazardous Waste Invest azMtat Pipeline Invest <br /> Cher Lead Agency Site gency: :EIQM DTSC EPA kL Site �ater: Quality Site Other Type Site <br /> x <br /> DESIGNATED EMPLOYEE ,'�. �/_ PROGRAM ELEMENT n lij, CLRRENT STATUS <br /> '73MER OF UNITS C7 EPA _D #, INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, ackn owledgs that all and/or project specific <br /> PHS-E,YD hourly charges associated with this facility or activity will be billed to the party identified as the iRiLLING PARTY on <br /> the Masterfile Record Information Form. <br /> I also certify that i have prepared this application and tnac the work to be performed will be done in accordance with all SAN <br /> ,30AQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AICT=iORIZATION TO RELEASE INFORMAT-10F. In, addili-on Tc _^.e ,n when <br /> the uroperty located at the aborre site address hereby authorize the release of any and all results, geotechnical data and/cr <br /> enJirorimenLai/site assessment information to SAN JOAQUIN COUNTY PU3LIC HEALTH SERVICES ENVIRObLWEN'.AT BPTTi! DIVISION as soon E_- <br /> it is available and at the same rime It is provided to Me or my represertati•,-e. <br /> DEADLINE DATES. Inspection: Current / / Prior <br /> "ee Amount Amount Paid Date of Payment Payment Type I Receipt 4 Check # Recvd By <br />