Laserfiche WebLink
SAN JOAQUIN COUNTY POST C E –SERVi—=S <br /> ENVIRONMENTAL HEALTH DIVISION <br /> SITE MITIGATION MASTERFILE RECORD FORM I 1 t /- <br /> GENERAL PROGRAM FILE: New Change Edit (P�ROG4) revised 5/23/94 <br /> FACT= ID # FACILITY NAME <br /> RECORD -ID # /� L' / G, ` / PRIOR DIST # PRIOR SWEEPS # <br /> Site Mitigation: adlle4cal Aase;Saent /CAP 1 Hazard a Waste 1--1 TS4at Pipeline Invest <br /> Dine= Lead Agency Site ency: I DTSC I I EPA I L Siteater Quality Site tic type Site <br /> DESIGNATED EMPLOYEE # O G 1 PROGRAM ELEMENT # ,/+� �J CURRENT STATUE <br /> NUMBER OF UNITS ( EPA ID #: (/ ' INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record <br /> SILL=NG AMMWLEOGEMENT: 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 Mascerfile Record Information Form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be dare in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date- - <br /> ARTHORI2ATION TO RELEASE INFORMATICN: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property lwated 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 COONTY POBLTC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as anon 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 /> Y3 <br />