Laserfiche WebLink
8-1@-14J�ts 10:2/AM r,KUM <br /> SAN JOAQUIN OM= PUBLIC HEALTH SERVICES <br /> _"VIRONMENfAL HEALTH DIVISION <br /> SITE MITIGATIaN MASTERFILE RECORD FOPW( <br /> GENERAL PROGRAM FILE: New �Change Flit (PROGS) revised 5/13/94 <br /> FACILITY ID # FACIL2Tf NAND ' , Z.L e,e,., r v d (-+647 <br /> ' <br /> �= <br /> RECORD ID a PRIOR DIST 11 PRIOR SWEEPS # <br /> ite Mitigation: vi o,rental Asseasme[e T/CAP cal Hazardous 'Waste Invest s:Mst Pipeline Invr*c <br /> cher Lead Agency Site gercy: WQw DTSC EPA' kL Site Acer Quality Site cher Type Site <br /> DESIG°I= EMPLOYEE # �C(� T CURRENT STATUS ' 4 <br /> NUMER OF UNITS : 1 cPA ID #: INSPECTION CODE <br /> Number of TARES linked to this PROGRAM record <br /> SILL:t+G ACSOZOWLZEYMMENTI I, the: undcrsigned o.rner. operator or agent Of same, acknowledge that all site and/or project spocific <br /> p%s-EHD hourly charges asscciaccd with this facility or activity will be billed co the party identified as the $ILLING PARTi on <br /> the Masterfile Record Information Forn. <br /> I also certify that I havc prcpared chis application and char the work to be performed will be done in accordance with all SRN <br /> JOAQUi:4 COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> P6��APDL;Ci:Ni'S SIGNATURE +`—i <br /> • y W e,C7 <br /> Title- Date; <br /> 2l'viI{ORI:S+-_I0N TO RELEASE INFOR14A.TIONe In additiea to the abave, when applicable, I, the owner, operator or agent of sane, of <br /> t)-.e praperty located at the above site addrs3a hereby authorize the rclease oP,any and all results, gootechnical data and/or' <br /> envizenmcntal/aitc asscssmenc information to SAN 30AQUIN COUNTY POBLIC Fla TH SERVICES ENVIROZ31MMAL FFEAL7A DIVISION sw anon as <br /> it is available and at the same time it is provided to mn_ or my repreeentative. <br /> DEADLINE DATES- Inspection: C4rrenc / / Prior <br /> Fec Amount Amount Paid Dace of Paymsnc Payment Type Receipt Check # Recvd By <br /> a-� - z� 77 5s6 5 � <br />