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 /> ?AGILITY ID # FACILITY NAME <br /> RECORD ID # PRIOR DIST # PRIOR SWEE S # <br /> Site Mitigation: Environmental Assessment ST/CAP Wcal Hazardous Waste Invest �azMat Pipeline Invest <br /> Other Lead Agency SiteAgency: WQCB DISC EPA L Site ater Quality Site I 10ther Type Site <br /> DESIGNATED EMPLOYEE # D g PROGRAM ELEMENT # /'% / CURRENT STATUS <br /> .NUMBER OF UNITS EPA ID #: y! // INSPECTION CODE <br /> :lumber of TANKS linked to this PROGRAM record <br /> BI'LLING 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 t the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar Stat d Federal laws. <br /> APPLICANT'S SIGNATURE 11 11� <br /> VTitle: Date: <br /> AUTHORIZATION TO LEASE INFORMATION: In addition to the above, when applicable, i, the owner, operator or agent of same, of <br /> the property ocated 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 a Receipt # Check # Recvd By <br />