Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New X Change Edit (PROG4) revised 5/23/94 <br /> 7 /// A <br /> FACILITY ID # y FACILITY NAME <br /> jf OR SWEEPS # <br /> RECORD ID # ./� PRIOR DIST # PRI <br /> Site Mitigation: Environmental Assessment ST/CAP Local Hazardous Waste Invest azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: IWQCB I <br /> IDTSC EPA PL Site acer Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # OG/ PROGRAM ELEMENT # D 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 'e 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 /> V pr- <br /> AUTHORIZATION TO RELEASE INFORMATION: In addit n to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site addre hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it s provided to me or my representative. <br /> DEADLINE DATES: Inspection: Current <br /> Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />