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DATE <br />Ly <br />SHADED ARE" FOR EHD UBE ONLY <br />San Joaquin County Environmental Health Department <br />nwUlmn rn r . f%nucr c=ppnPFRTv nWNFRI RFSPnNSIRLF PORTV ljvPnRNATYnAL• CHECKIF <br />GREEN FORM <br />SITE MITIGATION & LOP <br />UNIT IV <br />CdRRENnroNRLEWITH EHD n <br />PROPERTY OWNER NAME <br />1/i9L\eeA <br />8U9INEss1FAcwTYISITEiPR0IECT NAME <br />Q. w Q <br />(2-0 t qd l --4 3 2 - <br />SITE ADDRESS I PROJECT LOCATION OL <br />L I 7 <br />`U,Y2i <br />First <br />First <br />M1 <br />Last <br />PHONE NUMBER <br />BUSINESS NAME <br />E-MAIL ADDRESS <br />Owner Home Address <br />Mailing Address /fOIFFEREAfrfravnFaallty d rvsa a I Attention: orCare Of (opLtav+ai) <br />a <br />city <br />STATE ZIP <br />Owner Mailing Address <br />Mailing Address City <br />State <br />7JP <br />I ❑ CORPORATION -- INOIVIDUAL ❑ PARTNERSHIP ❑ GovERNMENT AGENCY ❑ RESPONSIBLE PARTY ❑ OT14ER I <br />SITE MITIGATION J,/ ENVIRONMENTAL ASSESSMENT _ VOLUNT Y CLEANUP _ WATER QUALITY _ HW PIPELINE I VESTIGATION _ LOP <br />FACILITY IO S INv/ AcccuNr ID PR RO AssloNtTO EMPLOYEE LEAs AtIENCy: EHO RWQCB — OTssC _EPA <br />C <br />FACILITYFILE! nnwPtFTFRUSINESS ISITEIPROJECT INFoRmanaw• <br />Is this a NEw Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? <br />Is this an ExISTING Project LOCATION but a NEw SCOPE OF WORK? <br />YEs ❑ No <br />YES No ❑ <br />8U9INEss1FAcwTYISITEiPR0IECT NAME <br />p <br />+y <br />I <br />SITE ADDRESS I PROJECT LOCATION OL <br />L I 7 <br />`U,Y2i <br />SUITE * BUSINESSHONE <br />CITY <br />,, — f iD . <br />$TATF� ■ LP Q <br />j <br />BOARD OF SUPEW41,80tt DIS"VOT LOCATION CODE <br />KEYS <br />KEY2 <br />- t <br />Mailing Address /fOIFFEREAfrfravnFaallty d rvsa a I Attention: orCare Of (opLtav+ai) <br />a <br />Mailing Address City G io <br />STA Z A ZIP „ <br />C fi\ �1 <br />Sic CODE <br />APN / <br />COMMENT: <br />THIRD PARTY BILLING INFO: Complete if Billing Party is dlfferentirom PrOpertj owner OrKOsponsIDIB rOrly /DenE1)?eac7O0ve. <br />SusimEss NAME [ J J.,ryL • .. ,,, w • Ro y' ] P - V � Attention: or -Care Of (opdonalj <br />Mailing Address v L• Pit HE <br />CITY STATE 010 ZIP <br />�2�1 J � V' CYl G 1 <br />for fees and charges I4[1C (THIRD PARTY BILLING <br />BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1, the undersigned Applicant, certify that I am the Owner, Operator, AuthoriredAgent, or Responsible Parry an eH.xtrFEls, <br />PENAi,77Fv, ENFoacEmFm,CHARCEs and/or HOUR/.}' CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTAnnRE10; for this site. I also certify that all <br />information provided an this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUTN COUNTv Ordinance Codes and/or <br />Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner, Operator, Authorized Agent, or Responsible Party fart project localed above under facility/site sddress, I <br />berebv authorize the release of any and all results, reports, and other environmental assessment information to SAN JOAQUIiN COUNTY ENV N EDTA HEA DEPARTMENT as soon as it <br />is available and at the same time it is provided to me or my representative. <br />APPLICANT NAME (PLEASE PRINT) O I SIGNATURE d <br />TITLE TAX ID # <br />/�Idt/AG �,s1,r,��rr�xr-Y 11Y <br />Approved By DaIW <br />Ace -v 011ice Processing Completed By Data <br />SITE MITEQJITION <br />FEE: <br />AMOUNT PAID <br />DATE OF PAYMENT <br />PAYMENT TYPE <br />RECEIPT S CHECK S RECEIVED BY WORK PLAN PE <br />