Laserfiche WebLink
DESIGNATED EMPLOYEE # <br /> <br />oosy PROGRAM ELEMENT # P7-50 CURRENT STATUS <br /> <br />NUMBER OF UNITS : EPA ID #: INSPECTION CODE : <br />Number of TANKS linked to this PROGRAM record : <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />SITE MITIGATION MASTERFILE RECORD FORM <br />GENERAL PROGRAM FILE: New Change <br /> <br />Edit <br /> <br />(PROG4) revised 5/23/94 <br /> <br />FACILITY ID # FACILITY NAME 4/114644. 7"eTeti.et ailtein <br />RECORD ID # PRIOR DIST # PRIOR SWEEPS # <br />'Other <br />Site Mitigation: <br />Lead Agency Site <br />)e. <br />-....- <br />Environmental Assessment <br />% <br />ST/CAP Local Hazardous Waste Invest 4azMat Pipeline Invest <br />Agency: RWQCB DTSC EPA gPL Site Water Quality Site Other Type Site <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 Feder WS. <br />APPLICANT'S SIGNATURE <br />Title: Date: <br />AUTHORIZATION TO RE E INFORMATION: In addition to the above <br />the property located at the above site address hereby authorize <br />environmental/site assessment information to SAN JOAQUIN COUNTY <br />it is available and at the same time it is provided to me or my <br />, when applicable, I, the owner, operator or agent of same, of <br />the release of any and all results, geotechnical data and/or <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />representative. <br />DEADLINE DATES: Inspection: Current / / ?rior / / <br />! Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />Ie...ak, 37/ '2 1