Laserfiche WebLink
DESIGNATED EMPLOYEE # CURRENT STATUS s?(/ PROGRAM ELEMENT # <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <br />Number of TANKS linked to this PROGRAM record <br />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 />".0.7 <br />FACILITY ID # ,..cNIbb \ S 1...,) 2- 2> FACILITY NAME d1,114) 4446,_ dit.„4,01„Aot csos 4 <br />RECORD ID # 0‘ 0 6 P2-- 1 63 lo PRIOR DIST # PRIOR SWEEPS # <br />Site Mitigation: Environmental Assessment UST/CAP Local Hazardous Waste Invest HazMat Pipeline Invest <br />her Lead Agency Site Agency: ?1( RWQCB DTSC EPA gPL Site dater Quality Site Other Type Site <br />3/0 <br />-• 3/2-- <br />3 <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 /> <br />Title: <br /> <br />Date: <br /> <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, <br />the property located at the above site address hereby authorize <br />environmental/site assessment information to SAN JOAQUIN COUNTY <br />it is available and at the same time it is provided to me or my <br />when applicable, I, the owner, operator or agent of same, of <br />the release of any and all results, geotechnical data and/or <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />representative. <br />DEADLINE DATES: Inspection: Current / / Prior / / <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />0-1C/45 225.-- 7 416-v_ /3/9 4-,ie-71 <br />LAN /443(0