Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM / <br /> GENERAL PROGRAM FILE: New Chan e 3 <br /> 4 Edit <br /> (PROG4) revised 5/23/94 <br /> FACILITY ID # /^ <br /> FACILITY NAME IFr <br /> RECORD ID # 1 V' <br /> PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: vironmental Assessment ST/CAP <br /> coal Hazardous Waste Invest <br /> azMat Pipeline Invest <br /> 4enc <br /> ther Lead Agency Site Y: WQCE DTSC EPA PL SiteI <br /> -ter Quality Site Other <br /> Type Site <br /> DESIGNATED EMPLOYEE # Q PROGRAM ELEMENT # <br /> WWW I CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: l�✓ _ <br /> INSPECTION CODE 3 <br /> Number of TANKS linked to'this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent If same, acknowledge that all site and/or project specific <br /> PHS-ERD 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: <br /> 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 representative. <br /> DEADLINE DATES: Inspection: Current / / <br /> Prior <br /> Fee Amount Amount Paid Date Of Payment Payment Type Receipt # Check # Recvd By <br /> " <br />