Laserfiche WebLink
SAN JOIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV <br /> ENVIRONMENTAL HEALTH DIVISION E l• V <br /> SITE MITIGATION MASTERFILE RECORD FORM 1 'J <br /> sq"Joq J 2010 <br /> GENERAL PROGRAM FILE: New Change Edit >(PROG4) revise 4/23/94 <br /> FACILITY ID # G rl /( FACILITY NAME <br /> RECORD ID # L) p L PRIOR DIST # PRIOR SWEEPS # l <br /> C Z °t 11 f^-w� S-"• 5 4n--�{oc <br /> Site Mitigation: nvironmental Assessment ST/CAP ocal Hazardous Waste Invest I azMat Pipeline Invest <br /> Cher Lead Agency Site gency: 1RWQCB DISC EPA PL Site' -ter Quality Site Other Type Site <br /> DESIGNATED EMPLOYEE # I� PROGRAM ELEM # l $� CDRRENT STATUS <br /> NUMBER OF UNITS EPA IO #: - INSPE ION 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 /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> r <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 -/-/- Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> to a O — ° vs I I o ✓ 0 L{ fir. <br />