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San Joa uin County Environmental Health Department <br /> DATE )� M R FILE RECORD INFORMATION "16119 GREEN FORM <br /> 6-�iIS _ SITE MITIGATION & LOP <br /> ftwfoAgEAIFOREHDusE_ONLY OWNER 100 CASEUNIT IV <br /> WINERFILE:ComPLEMP�RJO�1P'E1�1RT��Y1OWNERIRESPONSIBLE PARTY INFORMATION: CHECKIFOWNER CURRENTLYONFAEFIfMEHO <br /> aROPEAW OWNER NAME ljq](011 yVb SJ �CA)% <br /> First Mf Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> (`�U5 M <br /> Owner Home Address —7-7 �q 5, <br /> � ,[ / <br /> city rytil/ �/J zip �O <br /> Owner Melling Address <br /> Melling Address City State MID <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY ❑RESPONSIBLE PANTY ❑OTHER <br /> ,ITE MITIGATION_ENVIRONMENTAL ASSESSMENT INVOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAOILfIY fO# INv# ACCOUNT ID <br /> pOISZo� OPR# RORWOCB_OTBC_EPA_ <br /> Sz?. 1S <br /> I�NHLcI� <br /> 'ACILITYFILE: COMPLETE BUSINESS ISITEIPROJECT lwoRNAT/ON: <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 ❑ <br /> BUSINEBSIFAcv.nY/SRE/PRcUECT NAME 'a \ i��p�`-'/`TI� � = J�Ji� :r e— (zAr Rol, <br /> J(J 'r1VU�..t/ T�r L`fJ� 1-411�7)1C <br /> SRE ADDRESS/PROJECT LOCATON 00 Ny /� l AN t\1 g� SURE# BUSINESS PHO�yNyE <br /> Cm u .rY..\AM, STATE LP 99,2 /D <br /> SOAROOFSUPERwaORDlariRCT LOCAnonO a KEY1 KM �L// <br /> Meiling Address HDIFFERENTrrcm FadlRyAddrsss Attention:orCase Of rapponal) <br /> IF ILL UU1 I <br /> Meiling Address City r•� �°1 / �-� STATE LP <br /> SIC CODE APN AP � `7 -050-3 / COMMENT:OL-0 <br /> rHIRO PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orResponsible Party identifiedabove. <br /> BUSINESS NAME Attention:orCaro Of (optional) <br /> K-- <br /> Cm <br /> Address G4 S.` NGLN PHONE '? 1--7/�� <br /> Ubb``'tF 1�JJ /�� �,ryiy /3C.LL, Z�i2 Gv r c�9 `'U/' <br /> Cm G L K C-A 0'�C �f 1� /�(X- <br /> ACGpuA2r9Dpww for fees and Charges OWNER FACiLITy/BUSINESS CTHIRD PARTY BILLING <br /> nt 61Nf.nw CDael'1.IANCF ACKNOwLF.nCaa�r: I,the undersigned:applicant,certify that 1 am the Avner,Operator,AulAariud A914 ar Responsible Part),add I acknowledge that all Pmstrf FEES, <br /> 'FNAGTIE$ENFoRCEvcnr CHARGES and/or HOURLYCI Gu associated with this project eifi be billed tome at the address identified above as the ACCom7ADDAESS for lids site. 1 also certify that all <br /> aformation provided on this application is true and correct;and that all regulated aedvides will be performed in aucardance with all applicable SAN JOaUUIN COIMI'Ordinance Codes and/or <br /> Iluodards add Srtn and/or PEDERAL Lawa and Rrgulalinns. As the undersigned Owner,Operator,Authored Agent,or Responsible Party for the project IgFatcd above sender facility/site address I <br /> mreby authorin the rdcasc orany and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONME. HEALTH DEPARTMENT as soon as it <br /> s a,allahle and al the same time it is provided to me or my mprescmatirvc. <br /> APPLICANT NAME(Pt.EAae PRIHi)3�q '(� L/ �I/A (j]fi SIGN, _--- <br /> # <br /> TITLE /��r �7p /2_LSTV yet k TAR ID <br /> _Approved By Date _ AccpnNtp Office Proceeain9 Completed By Date �I <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: A 7 5-0 _I <br />