Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New-->�—Change Edit (PROG4� revised 5/23194 <br /> FACILITY ID # h r } FACILITY NAME <br /> RECORD ID # Tl �j � / /ter PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste invest �azmat Pipeline Invest <br /> L`he�XfGead Agency Site envy: WQCS DISC EPA L Site acer Quality Site Cher Type Site <br /> u` 4 <br /> DESIGNATEDEMPLOYEE Tit <br /> PROGRAM ELEMENT # 3 jb 3 CURRENT STATUS (� <br /> NUMBER OF UNITS EPA ID 4: v INSPECTION CODE <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 /> ?HS-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 chat I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> .IOAQUIN 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 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 / / Prior <br /> Pee Amount Amours[ Paid Date of Payment Payment Type Receipt # Check # Recvd ay <br /> � F <br />