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SITE INFORMATION AND CORRESPONDENCE
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2900 - Site Mitigation Program
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PR0507822
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SITE INFORMATION AND CORRESPONDENCE
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Last modified
6/23/2020 4:08:09 PM
Creation date
6/23/2020 3:21:22 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0507822
PE
2950
FACILITY_ID
FA0007782
FACILITY_NAME
EASTLAND PLAZA
STREET_NUMBER
548
Direction
N
STREET_NAME
WILSON
STREET_TYPE
WAY
City
STOCKTON
Zip
95205
CURRENT_STATUS
01
SITE_LOCATION
548 N WILSON WAY
P_LOCATION
01
P_DISTRICT
001
QC Status
Approved
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EHD - Public
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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION , <br /> •:'f1. <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GEnRAL PROGRAM FILE: New Change Edit <br /> A / f SPROG4y revised 5/23/94 <br /> it FACILITY ID # /X 7y-02 FACILITY NAME /J�77? � rfj} /1/ , , ti S <br /> f <br /> klAy <br /> •fir <br /> RECORD ID # RR �O �� PRIOR DIST # <br /> PRIOR SWEEPS # <br /> . <br /> . <br /> Site Mitigation: Environmental AssessmentST cal Hazardous Waste Invest zMat Pipeline Invest <br /> ther Lead Agency SitE gency: WQC8 DTSC EPA PL Site ater Quality Site ther Type Site <br /> DESIGNATED EMPLOYEE U `{AJ/ PROGRAM ELEMENT q 1�Z �I/ CURRENT STATUS <br /> x NUMBER OF UNITS EPA ID #r ` <br /> INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record r <br /> ;BILLING ACKNOWLEDGEMENT: I, the undersigned owner: operator or agent of same, acknowledge that all site and/or project specific x <br /> PHS-END hourly charges associated with this facility or activity will be billed t0 the party identified as the BILLING PARTY on <br /> z the Masterfile Record Information Form. <br /> ;:F2 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> u JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. `r"I <br /> w (9( <br /> 1 <br /> -1 <br /> 31PPLICANT'S SIGNATURE :''✓� <br /> rtf <br /> 'Title. <br /> Dater, - <br /> F AEMORIZATION TO RELEASE INFORMATION: In addition to the above,' when applicable; 1, 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 /> �9 environmental/site aaseasmsnt information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISMI as soon as <br /> it is available and at the same time it is provided to me or my representatives <br /> t DEADLINE DATES: inepcctioni Current / / '" Prior <br /> " Fee Amount /mount Paid' Date ok Payment•':-. Payment Type. Receipt # .Check #, , Recvd By <br /> X313.: 7. <br /> Z <br /> 11ng <br /> j� <br /> � +' i s'i r 4 a? t 1 Z •i1 r� �e � .,- i•:`� <br /> — �• -.� CJs <br />
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