Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New 'mange Edit (?ROG4) revised 5/23/54 <br /> FACILITY ID # FACILITY NAME 0 L�6 <br /> RECORD ID # 1 PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous 'Waste invest az.4at Pipeline Invest <br /> Cher Lead Agency SiteAgency: WQCB DTSCF1 EPA FPL <br /> Site ater Quality Site tier Type Site <br /> _ TDESIGNATED EMPLOYEE # /w ' PROGRAM ELEMENT # Q CURRENT STATUS <br /> NUMBER OF UNITS : ! EPA T_D #: 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 /> PHS-EHD hourly charges associated with this `acility 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 perfoz-ned 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: 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 iMALTH 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 J / <br /> Fee Amount Amount Paid Date of Payment Pa',-ne.^.t Tape Check # 13ecvc 3y <br /> 0 <br />