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SAN.JAUIN COUNTY ENVIRONMENTAL HEALTH E OARTMENT <br /> cc » GREEN FORM <br /> DATE —/� Z O�3 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION &LOP <br /> SHADED AREAS FOR EHD USE ONLY <br /> OWNER ID# CASE# UNIT IV <br /> CHECK IF OWNER/S CURRENTLY ON FILE WITH EHD <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: <br /> PROPERTY OWNER NAME 150 SS _ L5D <br /> FIRST MI LAST PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME <br /> OWNER HOME ADDRESS <br /> CITY <br /> /''y►�` <br /> OWNER MAILING ADDRESS <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> ❑CORPORATION INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION—ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP <br /> =FACILI- INv# AccouNr ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB—DTSC _EPA <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No I� <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No/❑_ <br /> BUSINESS/FACILfTYISITEIPROJECT NAME m//,�/ ./J/O� <br /> U(/ /y (/ J`� SUITE# BUSINESS PHONE <br /> SITE ADDRESS/PROJECT LOCATION 11-6 <br /> STATE ZIP ��^ <br /> Clrr n U <br /> (% KEY/ KEv2 <br /> BOARD OF SUPERVISOR DISTRICT �j' LOCATION CODE <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF OPTIONAL) <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> / ATTENTION:OR CARE OF OPrI NAL <br /> BUSINESS NAME J <br /> ^ UAA <br /> PHONE <br /> MAILING ADDRESS <br /> S STATE zipCITY S <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER <br /> FACILITY/BUSINESS❑ THIRD PARTY 4 BILLINt ' <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the(honer,Operator,Authorized Agent,or Responsible Parry and 1 acknowledge that all PERntITFEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed tome at the address identified above as the AccouNTADDRESS for this site. 1 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 SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL 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 DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) i/i 1 k QAn fqA1 lci6(/'7�V/V TAx ID# <br /> TITLE <br /> APPROVED BY <br /> DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WOR PLAN P <br /> FEE: �((jj <br />