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San Joaquin County.Environmental Health Department <br /> DATE �I MASTER FILE RECORD INFORMATION 66MFR19 GREEN FORM SITE MITIGATION &LOP - <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT V <br /> QWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY kwoRMAT/ON. CHECK/F OWNER CURRENTLVONFILEWITH EHD <br /> PROPERTY OWNER NAME =64 <br /> ;e .L'Q�fe/' (lei) O3o-32y['J— <br /> First M/ Last PHONENUMBER <br /> BUSINESS NAME � E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE Zip <br /> Owner Mailing Address <br /> I T ✓e <br /> Mailing Address City St'M ZIP 953 6 <br /> ❑CORPORATION ❑INDIVIDUAL ElPARTNERSHIP ElGOVERNMENT AGENCY ElRESPONSIBLE PARTY NuTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT V VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# - INV# ACCOUNT ID �` PR#!RO# "/�SSIONEDEMPLOYEE' LEao AoENOy�EHD'1, ''��RWQC�` DTSk'�EpAI <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> Is this a NEw Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES d No ❑ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No [R� <br /> BUSINEss1FAciLRY/SRFJPROJEI:T NAME IS 14 <br /> SITE ADDRESS/PROJECT LOCATION 1102,2- Weld P r. SurrE It BUSINESSPHONE <br /> CRY FJJ�A STATE ZIP <br /> d <br /> BOARD OF SUPERVISOR DISTRICT. LOCATION CODE <br /> Mailing Address ifOIFFERENThvmFaci/ifyAddress Attention:orCereOf(apf dw/) <br /> 2G C bels <br /> Mailing Address City STATE ZIP <br /> SIC CoDE FAPN* COMMENT' <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Panty identiriedahove. <br /> BUSINESS NAMEComes �'71_vei,S Ass06a�eS Attention:or Care IA(apffona!) <br /> Mailing Address jC(J PHONE <br /> SgODa 'S S4 §70) q?..v -a�°O <br /> CITY STATE zip <br /> bmetr til le 64 2 war <br /> AccayVTAmm-1s for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY$/LUNG <br /> RILiJNc..4�O COMrLIn:YCt;ACli;�otYLEDGM1tE]QT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Aullrorked Agent,or Respousibk Party and I acknowledge that all PER7,17T FEES, <br /> PEAZALTMS,E_W`0RCFHEYTCIiRGES and/or HOURLY CIL(RGES associated with tltb project will be billed tome at the address identified above as the ACCOANTADDRESS for this site I also certify that all <br /> inrormalion provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicabie SAN JO.a4ULN COUNTY Ordinance Codes amTor <br /> Standards and STATe and/or TEDEFUL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above ander facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other envi oumental assessment information to S A_N JOAQUIN COUNTY FNVIRON Nl rNTA 1,ItF.AI,Tit D 171ARTRIENT 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) SIGNATURE <br /> TITLE TAX ID# <br /> SiS - Z2 <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIG4ATION AQMO9UNT PAID DATE OF PAYMENT PAYMiENTTYPE RECEIPT# CHECK# RECEIVED BY WI�O(jRK P�jLAN PE <br /> 7 !;` 1� <br />