Laserfiche WebLink
SAM 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 /> FACILITY ID # �Qf 3 FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP jocal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site envy: WQCB DTSC EPA L Site ater Quality Site the- Type Site <br /> DESIGNATED EMPLOYEE # q y�)� I PROGRAM ELEMENT # 2�v CVRREHT STATUS <br /> NUMBER OF UNITS : LJ� EPA ID #: o 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 /> N/n/g6Pk.d 7. oGd�e27ta o:� (�ced�wac Q� u2U✓� � wu 3J .� w�w�l <br /> APPLICANT'S SIGNATURE <br /> Title: Date: 7,� y§ yy�"� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operat0Af WFIR'f 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 ENVIRONMENT VITM as soon as <br /> it is available and at the same time it is provided to me or my representative. °' <br /> SAN JOAUUint <br /> Tti V• O o7 7 PUBLIC HEALTH SERVICES <br /> 3 9 oNVIRONMENTAL HEALTH DIVISION <br /> DEADLINE DATES: Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Re—d By <br /> a3 '� 2 �y,Dd a /7/qG Baa <br />