Laserfiche WebLink
• SAN 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 /> ,v <br /> FACILITY ID # P ,;1 FACILITY NAME S+OCk-+Q� Sau. j S Ga— – g <br /> ,�YlaI ec o, <br /> RECORD ID # PRIOR DIST # J !L PRIORSWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP ocal Hazardous waste Invest azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: IRWQCB DISC EPA kL Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # O w0 / T <br /> 1 — <br /> ROGRAM ELEMENT # ENT 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 protect 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: G`NU r ON M e/, ! I""a l y s� 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 /> 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 i Date of Payment Payment Type Receipt # Check # Recvd By <br /> ' <br />