Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> Edit (PROG4) revised 5/23/94 <br /> GENERAL PROGRAM FILE: New Change �,f^�/—/ <br /> 7v„ <br /> FACILITY ID # Do 1 Al a`7 FACILITY NAME I 'J' '"' ' <br /> RECORD ID # D5 , 1 D 7 6 PRIOR DIST # PRIOR SWEEPS # <br /> ite Mitigation: E.n <br /> ental Assessment T/CAP al Hazardous Waste Invest �zMat Pipeline Invest <br /> Other Lead Agency Site \\\ WQCBDTSC EPA L Site ater Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE # D O PROGRAM ELEMENT # 9 �� CURRENT STATUS <br /> NUMBER OF UNITS <br /> EPA ID #: 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 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 yto be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> t 1 <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property locate at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/s• a 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 /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />