Laserfiche WebLink
SAN 70AQUIN 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 /> FACILITY ID # p p / Z 9 FACILITY NAME /'].i /_ 4ZAIN <br /> P S PRIOR DIST % PRIOR SWEEPS # <br /> RECORD ID # /c—(/ dam( <br /> Site Mitigation: nvironment Assessment ST/ cal Hazardous Waste Invest zMat Pipeline Invest <br /> Cher Lead Agency Site CB DISC EPA L Site ater Quality Site chez Type Site <br /> ZR.s� <br /> DESIGNATED EMPLOYEE # O(0l ' PROGRAM ELEMENT k CURRENT STATUS <br /> NUMBER OF UNITS EPA ID #: INSPECTION CODE <br /> Number of TANKS linked to this PROGRAM record : <br /> BILLING ACKNOWLEDGEMENT: 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 a Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> Date: <br /> AUTHORIZATION TO RELEASE INFO ION: 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 REALTH 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 />