Laserfiche WebLink
0 <br /> 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 S/23/94 <br /> FACILITY ID # bo '1 b� 1 FACILITY NAME p ELj/t PLs4-T)AI7 <br /> RECORD ID # O O S2 PRIOR DIST # PRIOR SWEEPS # <br /> <�lv 5- 54-MKr56us S� <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency Site ency: WQCS OTSC EPA PL Site Ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # 6'2,� PROGRAM ELEMENT # 2 1 S 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 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. ) q <br /> SAN JOAQUIM <br /> E <br /> EALTIi() <br /> DEADLINE DATES: Inspection: Current / / Prior / / FP"pT�AL"! <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ate' 6v a i w o ✓" Z ,; <br /> N <br />