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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> ZI SITE MITIGATION&LOP <br /> SwsDEpAREASFOREMDUSEONLY OWNER ID# OIAI(� �y CASE NIT IV i <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY/NFoRwT/oN: OHFCKrF OWNER CURRENTL VON FILEW?H EHD <br /> PROPERTY OWNER NAME 6 on n (201) t30-32v5- <br /> First Ml Last PHONE NUMBER - <br /> BUSINESS NAMEE-MAIL ADDRESS <br /> 7rA c y VA;-9,0d $ctioa 1 J)iS* t:-f' b cta� r +04d.net <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address IRIS' W+ Lowe Am-le <br /> Mailing Address City Tra S_64 Zip3/ <br /> [I CORPORATION [IINOMDUAL El PARTNERSHIP ElGOVERNMENT AGENCY El RESPONSIBLE PARTY M OTHER - <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT Z VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# C <br /> ACOUNTID <br /> p � ABBIGNEDFJtPLOYEE�- LEAOAOf:NCY EHD/ � rc.YrVC1Il ": dT$��,EPA II�'I' <br /> 7y/�7-�/( /,,�.-�1i-� ^yy^ <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION:` <br /> Is this a NEw Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EXISTING Project LOCATION but a NEw SCOPE OF WORK? YES ❑ No 021, <br /> BUBINEBSIFAOILITYISIrtJPROJECT NAME N44 <br /> +� <br /> SITE ADDRESS/PROJECT LOCATION 11022- YswArdSUITE# BUSINESS PHONE <br /> CITY S �k�hr, 1F1'.�i STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICTLOCATION CODE- 'KEY1 - KEY2 - <br /> Mailing Address NO/FFEREMTfromFaadify Address Attention:orOare Of(ophWra/) <br /> ec Owoer �c8r <br /> Mailing Address City STATE ZIP <br /> SIC CODE 7-11�p <br /> N sE COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orResponsible Party identifredabove. <br /> BUSINESS NAME Attention:orCare Of(Ophbaw) <br /> Cortes -P.ovar Assaaek+- es <br /> Mailing Address PHONE <br /> 5-100a 's S� 570 q2,0 —�'�°O <br /> Cm STATE ZIP <br /> breY vI le !2 116 D <br /> ACC4t wADoRESS for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> RILLIN(;_4ND COMI'LIANCF:Actc,4oli'LEDGAIFNT: 1,the undersigned Applicant,certify chat I am the Owner,Operator,Aufhor;zed Agenr,or Respousible Party and I acknowledge that all PERA17T FEES <br /> PEN,+LTTES,EN>•bRCEMF_M'C.fLaRCF.S and/or HOURLYCmRrES associated with this project will be billed tome at the address identified above as the ACCOU'yTAnDRESS for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable S.+N J04QULN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDEPUL Laws and Regulations As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFPARTMFNT as soon as it <br /> is available and at the sauce time it is provided to me or my representative. , <br /> APPLICANT NAME(PLEASE PRINT) -Fa`aA )l�Aan SIGNATURE <br /> TITLE TAX ID# \J <br /> S v iS+_ 47-29 <br /> A sed B Date Accounting OMos Proceseing Completed By Data <br /> SITE MITIGATION AMOUNT PAID D.AuT�IEDnFPAYMENT PAYMENTTYPE RECEIPT# CHECK <br /> # RECEIYEOBY WORKPLANPE <br /> FEES&?C) 3 1 U 1"`z•/� E CT 1 L 7� l.' <br />