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 /> FACT_LITY ID # fiyJTD r() Q7J5 FACILITY NAME Rl.q,l <br /> RECORD ID # ?65d 3 3 o PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: nvironmental Assessment ST/CAP cal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: IRWQC13 DTSC EPA L Site �ater Quality Site FTher Type Site <br /> DESIGNATED EMPLOYEE # b 2 1 1 PROGRAM 3LE ANT # a CURRENT STATUS <br /> NUMBER OF UNITS : EPA 1D #: 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 /> tae 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. <br /> !-". �/a 7,-5-,�?'? <br /> DEADLINE DATES: Inspection: Current / Prior / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> a�� a�q .- lel to y ✓ 05 c/� <br />