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 /> PACILI7Y ID # \ tb 3 g FACILITY NAME <br /> RECORD ID # -7 6-3 <br /> PRIOR DIST # PRIOR SWEEPS # <br /> e Mi 'g ion- ironmental Assessment T/CAP cal Hazardous Waste Invest azMat Pipeline Invest <br /> then Lead Agency Site l gency: WQCS DISC EPA L Site ater Quality Site they Type Site <br /> DESIGNATED EMPLOYEE # DW PROGRAM ELEMENT # -70 $Q CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Numberof 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 cc Che party identified as the BILLING PARTY on <br /> the Masterfile Record Information Forma <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 RE INFORMATION: In addition to the above, when applicable, I. the owner, operator or agent of same, of <br /> the property to ac ac 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 /> itis 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 Tyne Receipt # Check # Recad By <br /> 3tv <br /> � D 5. 28-� . •��� � �8q�'1� <br />