Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROMM71,L HEALTH DIVISION <br /> 3ITTION MAS`lERFILE RECORD FORM <br /> GENERAL PROGRAM FILE.. ,-e <br /> g....t <br /> . (PRO04) revised 5/23/94 <br /> FACTLPTY ID # <br /> FACILITY NAME51 CLU4 <br /> -4s[O r p fly a 4e <br /> RECORD ID # <br /> PRIOR DIST p54o PRIOR SWEEPS # <br /> kiteation: rorssental Assessment /CAP1 Hazardous waste Investt Pipeline Invest <br /> Agency Site cy, <br /> DTSC EPA Site ater Quality Site <br /> r Type Site <br /> DESIGNATED EMPIAYEE p O (� PRO�MM O =M= STATUS <br /> NUMBER OF UNITS EPA ID #: <br /> `— 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. <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: �NU,rONMeni-ft I ST 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 /> DEADLINE DATES- Inspection: Current / / Prior <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Re <br /> Z3 �Z3 3-'17-17 ✓ 0�3b <br />