Laserfiche WebLink
SAN OOAQUIN COUNTY PUBLIC WEALTH SERVICES <br /> o }NVIROI49NAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM PILE: New Change Edit (PROG4) revised 5/23/94 <br /> FACILITY ID # �"�I FACILITY NAME <br /> RECORD ID # ,-r PRIOR DIST # PRIOR SWEEPS <br /> f <br /> Site Mitigation: yEnvirionmental Assessment /CAP cal Hazardous Waste Invest zMat Pipeline Invest <br /> they Lead Agency Site ency: . DISC EPA L Site ter Quality Site Cher Type Site <br /> DESIGNATID EMPLOYEE # ''1 PROGRAM EIZ`WT # yG . S CURRENT STATUS <br /> NUMBER OF UNITS / EPA ID #: V 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 /> 4 <br /> pHS-EHD hourly charges associated with this facility or activity will he billed to the party identified as the BILLING PARTY on <br /> t Pthe Masterfile Record Information Form. <br /> ) r <br /> s_ <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 /> FEES z X99 <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 /> i, <br /> .,.: <br /> environmental/site assessment information to SAN JOAQDffi COUNTY PUBLIC HEALTH SERVICES ENVII20!?tENAi. HEALTH DNZSION 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 / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # C1eck # Reevd By <br /> en <br /> N <br /> x� <br />