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SAN SQUIN COUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> DAIi MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED.:REFS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: <br /> CHECK IF OWNER is CURRENTL Y ON FKE WITH EMD Ll <br /> F,` i u S (Zc, - <br /> PROPERTY OWNER NAME LI 5(D LA 14?�i i11 <br /> FIRST Mf LAST PHONE NUMBER <br /> BUSINESS NAME { E--MAIL ADDRESS <br /> Avsf,n � o,c4 &!� tew&S tsar-"Yvers lot iios �� a��o corn <br /> OWNER HOME ADDRESS <br /> t y co 3 <br /> CITY C Ct STATE C A ZIP 3 <br /> OWNER MAILING ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARI NE RSHIP C GOVERNME NI A(iF NCV ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ­ ENVIRONMENTAL ASSESSMENT? VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# AccouNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�_RWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES CS 10 ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? )YES ❑ INo (� <br /> BUSINESSIFACILITYISITE/PROJECT NAME � Rc�c� �I(� c'(--`-s <br /> SITE ADDRESS 1 PROJECT LOCATION rF\ r 1 w t� p (� SUITE# BUSINESS PHONE <br /> rS�C Utl Ot' �lK{'1r1R C1 IV 1�--1 —rC1111 <br /> CrtY STATE ZIP l S 3 3 <br /> CA <br /> =81-0OFISOR DISTRICT LGCATKNJ CODE i. G C.I/ KEYi KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> z G <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION: CARE OF(OPTKWAL) Dave g u c.L'MCLGk�4V n dnS <br /> L-t—rzL LoncA or <br /> PHOIIE e11 In- 3 7 5- <br /> MAILING ADDRESS 5 3 Z I -�-I`�e' <br /> Z bo0.t mars Av <br /> STATE ZIP <br /> Cor <br /> West Sc�crc1rr-�nt� C q5 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING® <br /> BILLING AMD COMPLIANCE ACKNONLEDC1IENT: I,the undersiped Applicant,certif}-that I am the Owner,Operator,Authorked ABCnf,Or Responsible park'and I acknowledge that all PERMIT FEE%. <br /> pENALTIEs,EjX'F0RCE.VEVT CHaRGE.5 and/or HOCRLFCHARRGES associated with this project will be billed to me at the address identified above as the.4CCOV.N7.4EIDRF-.v for this site. 1 also certif}%'that all <br /> D <br /> information provided on this application is ye and correct;and that all regulated activities will he performed in accordance with all applicable S.stt JOAQLTN COUN7y ORDINANCE CODES audlor' <br /> STANDARDS and STATE and/of FEDER'U.Laws and RECLLATIONS. As the undersigned Owner,Operator,Au11torked.4gen4 or Responsible Parry-for the project located above tinder facility/site address,I <br /> hereby authorize the release of am and all results,reports,and other em ironmental assessment information to SAM JO,IQUIN COu:%ri EMMUN&MMAL HEALTH DEPAKTdLEA'r as$oon as it is ayailabbe <br /> and at the same time it is provided to me or my representative. <br /> ct u r G� q <br /> APPLICANT NAME(PLEASE PRINT) L L O n SIGNATURE <br /> TITLETAX ID# G„ O 1 ot 1 <br /> enCj�i ne e r O y �D c� Z <br /> APPROVED BY DATE �It ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION A NT PAID j��DA�TE �PAYMENTPAYME <br /> TYPE RECEIPT# CHEECCK# RECEIVED BY WOORKPLAN PE <br /> FEE: , 125- T / (C��3� ��l�C T /�! J <br />