Laserfiche WebLink
* SAN JOAQUTN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Rdit (PROG4) revised 5/23/94 <br /> FACILITY ID # OO �VV FACILITY NAME �G/V ( "�✓-T'�" " <br /> RECORD ID # YYYY�«�r� PRIOR DIST # PRIORY SWEEPS # <br /> 6 5-e <br /> Site Mitigation: ironmental Assessment T/CAP cal Hazardous�Wa�ste Invest azMat Pipeline Invest <br /> Cher Lead Agency Site ency: WQCB DISC EPA L Site A ater Quality Site Cher Type Site <br /> (� a�65� <br /> DESIGNATED EMPLOYEE # I..Z t PROGRAM ELEMENT # ] I y`� CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 /> Lfw' <br /> DEADLINE DATES: Inspection: current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> lai `(/ZbfoS OS FSS 3 <br /> 0 <br />