Laserfiche WebLink
I?" <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> .: SITE MITIGATION MASTERFIL6 RECORD FORM c <br /> �CENSRAL PROGRAM FILE: New X_X _Change Edit {pRDG4) revised 5/23/94 0 <br /> .; <br /> FACILITY ID $ 9 7 VO FACILITY NAME 120 ' South Beckman Road Lodi 'CA <br /> RECORD ID 9 <br /> PRIOR DIST PRIOR SWEEPS A <br /> 1 <br /> Site Mitigation: XX Environmental Assessment 5T/CAP 1,0cal Hazardous 144ste Invest zMat Pipeline Invest <br /> i.. <br /> Other Lead Agency Site Ngency: FW= <br /> DTSC EPA PL Site ' -ter Quality Site F <br /> Type Site <br /> NDESIGNATED EMPLOYEE PROGRAM ELEMENT iCUR4RENT STATUS �9 <br /> NUMBER OF UNITS EPA ID 0: ' ✓✓✓ INSPEC ION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> Ai BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, Ackhowledlie 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 /> f_the Masterfile Record Information Form. ! S <br /> 'I also certify that I have prepared this application and that the work to be performed J t be done in accordance with all SAN <br /> Is JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws, <br /> rAPPLICANP'S SIGNATURE-:- <br /> ;.zitie: Authorized_ Agent/ Geologist Date; October 21 1996 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above,' when applicable, I, the owner, operator or agent of same, of r <br /> .the property located at the above site address hereby authorize the release of anyiand all results, geotechnical data and/or <br /> r e=ironmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIOIJ as soon as <br /> ;it is available and at the same time it is provided to me or my representative. <br /> I . <br /> DEADLINE DATESi Inspection: Current / / Prior <br /> :- - Fee Amount > Amount Paid Date of Payment .[-, Payment Type Receipt I Check 9 Recvd By rr <br /> r <br /> I <br /> ' � "s.ti <br />