Laserfiche WebLink
PAYMENT <br /> gECEIVED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T �[y9(IV+ <br /> 96 <br /> ENVIRONMENTAL HEALTH DIVISION APR <br /> SITE MITIGATION MASTERFILE RECORD FORM SAN JO, 4UIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH OIV1SION <br /> GENERAL PROGRAM FILE: New ' ) Change Edit (PROG4) revised 5/23/44 <br /> FACILITY ID # i/ FACILITY NAME 71'tx< 15;7x <br /> RECORD ID # �I /] PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: Environmental Assessment ST/CAP cal. Hazardous Waste Invest �azMat Pipeline Invest <br /> ther Lead Agency SiteAgency: �WQCB DTSCT]EPA L Site �ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # n/ PROGRAM ELEMENT # '`�O CURRENT STATUS �T7 �/�IA49-V <br /> NUMBER OF UNITS V V EPA ID #: I 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, n <br /> I also certify that I have prepared this application and that the work to be performed will be done inPa" XM01ith_ all SAN <br /> 6" <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> �i II#r'e . <br /> Q1 Q, � �---- SAN JOAOLio,APR 10 1996 <br /> u11.1r,! <br /> APPLICANT'S SIGNATURE <br /> H AI_T..H SERVICES <br /> r-WRONMENTAL HEALTH bIVISIUV <br /> Title: � I"" ! �rsl l"tFGI� �n�f� Date: �`�I7� <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 /> Z9.502OVe0 423s�� _5 /6 OF <br /> a, <br />