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San Juin County Environmental Health vn artment <br /> (� «MFR» GREEN FORM <br /> DATE I MASTER FILE RECORD INFORMATION <br /> SITE MITIGATION& LOP <br /> SHAOLD AUAS FQR-EHP.LMF QNLy OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPL`ETETHEFOLLOWING PROPERTY OWNER/NFORMAT/ON: CHEcHIF OWNER CairREAtrtroNFiLEWITHEHD p <br /> PROPERTY OWNER NAME slvw.i, O 1e—+rty.- (SS4) 4444 45—GqQ K <br /> J��r���AAA...AAMJA��//�.` First MI Last PHONE NUMBER <br /> BUSINESS NAME // E-MAIL ADDRESS <br /> Ca j-trV'-AS Q i S-lTi t�f b hr i�t . o le+'u-M—kf. CJA. a,) <br /> Owner Home Address <br /> - --. .$. i✓l S-k� 1 I-e o <br /> City STATE ZIP <br /> FmnoCdr g37z1 <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY,HW PIPELINE INVESTIGATION_LOP_ <br /> ��:llt�• �i� fix'#xF.:'%R v�S':tl',�'#t n. �..t .Y s v tr�,,,.'.'E, ..}..tur <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE AfFORMAwm <br /> Is this a NEW Business LocATtON not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITYISITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY '_ STATE ZIP <br /> i I S Lo 4 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 Ej- <br /> Mailing <br /> Address iIDIFFERENTfrom FacilltyAddness Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC RODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:oro re Of (o t10 a1J <br /> Geo <br /> Mailing Address PHONE <br /> 3-160 Gold Qokf 'Ut *M Cal(,) 852-9rr$ <br /> CITY If�t� C A STATE LP <br /> ft11 TSNs.7��t� CIS-N-2- <br /> AccowAymEw <br /> for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Omer,Operator,or Anthorked Agent of this Business,and I Acknmvledge that all PERART FEES, <br /> PENALT<rs,F.NFORCEmENrCRARGF.s and/or HOUR6FCimnGrs associated with this operation will be billed to me at the address identified abave,as the AcCoum*e4Pz REss for this site. I also certify that Ili <br /> information provided on this application is true and correct; and that all regldnted activities%rill be performed In Accordance with all appllCable SAN JOAQVIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/m•rEDRRAI,Laws and Regulations. As the undersigned owner,operator,or agent of the property located At the above facility/site address,1 hereby authorize the release of <br /> any and ail results and environmental assessment information to SAN JOAQUIN COUNTV ENVIRONMENTAL HEALTH DEPARTM NT AS soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) , �'at�( SIGNATURE <br /> TITLE TAX ID# <br /> _ �t„ntov� Sd� GeolDa�s�- _ <br /> Approved ey ! vat Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVGO BY WORK.PtiVl P . <br /> Fr.r:$ — �— <br />