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 5/23/94 <br /> FACILITY ID # D ()a — FACILITY NAME �aj� <br /> RECORD ID # PRIOR DIST # ?RIOR SWEEPS i <br /> Site Mitigation: Environmental Assessment T/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> XCher Lead Agency Sit envy: I IRWQC13 <br /> OTSC EPA L Site I ate, Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # 0 Q PROGRAM ELEMENT # Z 9�y� CURRENT STATUS <br /> NUMBER OF UNITS : 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 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: / Date: <br /> AUTHORIZATION TO RELEASE INFO TION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at t 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 /> D/moi 76- 7 <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recd By <br /> 9� -�Y <br /> tit <br />