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 <br /> _(PROG4) revised 5/23/94 <br /> FACILITY ID # FACILITY NAME /�►V�/l v <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> other Lead Agency SiteAgency: �WQCB DISC EPA L Site ater Quality Site I 10ther Type Site <br /> aro <br /> sG 3�Z <br /> DESIGNATED EMPLOYEE # PROGRAM ELEMENT It 2'? S� CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> :lumber 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 applicati that the work to be aerfozmed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, ate 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 /> Fee Amount Amount Paid Date of Payment Payment T <br /> Receipt # Check # Recvd By <br /> G y. .. <br /> 0 <br /> FILE <br />