Laserfiche WebLink
3 <br /> T <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION '. <br /> SITE MITIGATION MASTERFIL8 RECORD FORM <br /> GENERAL PROGRAM FILE: New C Change Edit ;PROG41 revised 5/23/94 <br /> FACILITY ID 7 FACILITY NAME A C-t s rj04 JA C,-5 U A V <br /> RECORD ID # y Jp �Sz b 7 PRIOR DIST # i PRIOR SWEEPS # <br /> Site Mitigation: Environmental AssessmentST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQCB DTSC EPA L Site �ater Quality Site then Type Site[ I <br /> i <br /> DESIGNATED EMPLOYEE # r0 <br /> 'Z�� TPROGRAM ELEMENT # Z S O 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 /> i <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 / / Pripr <br /> Fee Amount Amount Paid Date of Payment Payment Type ..Receipt # Check # Recvd By <br />