Laserfiche WebLink
� s <br /> SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL HEAL—r1 DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM <br /> GENERAL PROGRAM FILE: New Change Edit (PROG4) revised 5/23/54 <br /> FACILITY -TD # I FACILITY NAME I 14"1 <br /> ro /A) <br /> .RECORD ID O ` \ Z PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmeyal Assessment ST/CAP :,ocal Hazardous Waste Invest �azMac Pipeline invest <br /> Cher Lead Agency Sitegency: WQCB D- <br /> SC EPA <br /> __FL <br /> Site �azer Quality Site I Ttner Type Site <br /> DESIGNATED EMPLOYEE ik1::� PROGRAM ELEMENT n 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 or. <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 STLN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTIT 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 / J Prior / <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 9 I Check I Recvd By <br />