Laserfiche WebLink
San Joaquin County rnvirormental Health Department <br /> DATE uZ I&STER FILE RECORD INFORMATIONOFRf1 GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHADED AREASrOR EHO UPEjQ&Y OWNER IQ11 a y CASE# —] UNIT IV <br /> OWNER FILE:COMPLETETHE'FOLLOW_ !NO PROPERTY OWNER INFORMATION. Gwcxir OWNER OuRRemyONF/LB WITH EHD <br /> PROPERTY OWNER NACRE <br /> tail,^l iNf Lost PHONENUMBEt <br /> "AILADORess <br /> BUSINESS NAME <br /> Owner Home Address <br /> City STATE LP <br /> Owner Mailing Address t i <br /> m V Mailing Address City 1 State ZIP1 H 5 3-3 <br /> ! CCRPORATIONIA INDIVIDUAL❑ PARTNERSHIP❑ Feo AOENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVES11GATII/ON LOP_ <br /> FACILITYID# INV# ACCOUNT ID PR#ifRO# AS&GNEoEMPLOYEE LEAOAOENCY:EHDRWQCB X...DTSO,�..EPA___:_ <br /> 7 3�l2 _ ' <br /> PRO 3 9(�f -- <br /> FACILITY FILE COMPLETETHEFOLLOW(NG BUSINESS/FACILITY/SITE INFORAIAT/ON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExIST-INO Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No l ( <br /> BUSINESaiFACIUTYi.S`rrE NAME <br /> SITEAODRESS /]D SUITE# BUSINESS PHONE <br /> X11 G <br /> CIT, STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEY1 KEY2 <br /> Mailing Address irD/FFERENrlromFaciW Address Attentlon:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> 810 CODE APNk nay 070 06 COMMENT: <br /> THIRD PARTY BILLING INFO: Compllote if Billing Party is different from Property owner or Facility Operator identified above. <br /> BUSINESS NAME /". 2 p . Attention:orCare Of(opUonalJ <br /> Mailing Address G1f 1 l•� V, PHONE <br /> n -TOC V "i <br /> CITY STATE ZIP <br /> YSK72 <br /> AcjCOUNTADORE88 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> HILL ING AND OvIPI.IANcF,Act< owi,RnGvrIN : ],(he undersigned Applicant,certify that I am the O»uer,Operarar,or Authorized Agent of this Business,and I acknowledge that all PERsfirh'94 <br /> Prx.0 TlEs,CNFORCEAtENr0LIRGES andlor 11ouRLYCHARGES 1SSOCIatCd with this Operation wilt be billed to meat the address identified aboveas the ACY:0VNr ADDRESS for this site, 1 21t certify Chv <br /> all information provided on Ifis application is true and currml;and that all regulated activities will be performed In accordance with all applicable S,vj &AQLIN COUNT•Ordinance Codes and/or <br /> Standards and STATt:andtor rEDrRAL Laws and Regulations. As the undersigned owner,operator,or axent of the property located at the above factlityAlte address,I hereby aW horiie the release of <br /> any and all faults and environmental assessment I formation to SAN JOAQUIN COUNTY ENVIRONMENTAL]IF-4-I'll DEPAR ENT as scI6 alit-Ir-avall (ile and atthe same time it is <br /> provided tome or my representative. / / /-/' <br /> APPLICANT NAME(PLEASE PRINT) f - _ 14' � SIGNATURE <br /> TAX ID# <br /> TITLE - <br /> ;� t. �:2,_. d f c 7 /0A1496 1 <br /> A proved By Data Accaunung Office Process nq Completed By Dato <br /> SITE MIT13ATION AMOUNT PAID 1 DATEOFPAYMENT PAYMENTTYPE RECEIPTS CHECK CC.IV ED BY .WORK PLAN PPw <br /> FEE:$ <br />