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DATE San Juin County Environmental Health partment <br /> Q <br /> MW-ER FILE RECORD INFORMATION �E ;7r GREEN FORM <br /> 9�9 FOREHO USE ONLY OWNER ID# 5'�1,662.4 <br /> ,6 rt4 SITE MITIGATION & LOP <br /> CASE# v `"C6Z7 UNIT IV <br /> OWNER FILE.CoMPtETETNEFoctowlNc <br /> PROPER TYOWNERINFORMA770N.• ✓aGG2 <br /> CHECK/F OWNER CUaRENTLrONF/LEW/TH EHO <br /> FNEA <br /> ER NAME Lec L'on�-a.�{- <br /> Ilammonc� (401) Syy -SB26 <br /> First Mi <br /> BUSINESSE nD c Last PHONE NUMBER <br /> (�nlo✓) r�1�lL EMAILADORESS n <br /> Address DµAMMGND PuP.STATEZIP <br /> Address <br /> STop logo <br /> s City I <br /> Dmct(gp state ZIP68179-/G3o <br /> CORPORATION t1Q INOIVIOUAL❑ <br /> PARTNERSHIP❑ FED AGENCY❑ <br /> SITE MITIGATION_,ENVIRONMENTAL ASSESSMENT ✓ OTHER❑ <br /> VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID <br /> OO/I.r l/ PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD <br /> /r.• -^JJ ISI(AOS PQOS/S Jr1r JO KA/DY _�RWQCB_DTSC_EPq_ <br /> FACILITY FILE COMPLETE PYEFOLLOW7NG BUSI NESS/FAC ILITY If SITE/NFORMA 770N.. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but NEW TYPE Of regulated Business? ❑ <br /> BUSINESSIFACIUTYISITE NAME YES ❑ NO ElCJnron PactItc Qa;IroeLr� - Ar-Ar-&7-� fry crF P / <br /> SI1EAODRE33 o00 IU(I.YrW.S� <br /> I �` ROS eon• M P �S•66 D?F Md S✓YAJ• SUITE# BUSINESS PHONE <br /> CITY -r (/1 <br /> �rcncGt STATE ZIP <br /> BOARD OF SUPERVISOR DISTaclygddress <br /> !A <br /> Ic`" <br /> 1 <br /> LOCATION CODE EY2RY 1 <br /> Mailing Address f,0/F, m K <br /> 1400 D„ A 14re �&TOp IC3o Attention:ozCamOftopVOeq <br /> Mailing Address City ✓/" W• I•CL yt <br /> Dn10 1 Ll STATE ZIP <br /> SICCoDE APN# NE 681'7q - IDZp <br /> / COMMENT: <br /> L1 ^ l <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identif/ed above. <br /> BUSINESS NAME I <br /> COr1E — V ` AtleMion:orCare Of toptlana/J <br /> Mailing Address p [ / I p /♦� B <br /> 5 {OD I�L MJF' L� �UFt I� rT PHONE <br /> CITY II <br /> Em Lr VIItL STATE ZIP <br /> C q'1/p0 <br /> A—=0&EAAWFM for fees and charges OWNER <br /> FACILITY/BOSINESS THIRD PARTY BILLING ✓ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: f,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMtrFErs, <br /> PEIDA "T ?ENPoRCEMrNTCHAHGF and/or HoUrstyCH,u wassociated with this operation will be billed to me at the address identified above as theAccormTgpp {or this siM. Ialsocertifythat <br /> all information provided on this application is true and correct;and that all regulated actMfies will be performed in accordance with all applicable SANI)NTAD N Mfort Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulation S. As the undersigned owner,operator,or agent ofthe property located at the abov¢facility/Site address,IUNTY authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon to it is available and at the same filea it is <br /> provided to me or my representafive. <br /> APPLICANT NAME(PLEASE PRINT) �aN SClL(� SIGNATURE �/r•�'. r <br /> TITLE S✓ • �I'ose.c.Y'- CPA <br /> / Ck'A <br /> TAX ID# <br /> paw- <br /> Ap roved By Data Accounting ice Processing Completed By <br /> SITEMITIGATIONAMOUNT PAID DData <br /> ATE OF T� <br /> YMENT PAYMENT TYPE RECEIPT# <br /> FEE:!' 1. CHECK# RECEIVED BY WORK PLAN PE <br /> 2q�� <br />