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San Jor -in County Environmental Health Dooartment <br /> a�� GREENFORM <br /> DATE MAS�'ER FILE RECORD INFORMATION SITE MITIGATION &LOP <br /> UNIT IV <br /> CASE# <br /> OWNER ID# <br /> S AD A E F REHDL ggK-Y 0 / r �l� <br /> OWNER FILE:COMPLETE PROPERTY OWN ERI RESPONSIBLE PARTY INFORMATION, ORTaGWNERCURaENnyoynLEwiTHEHD <br /> fje�cb y 8- �54J <br /> PROPERTY OW NER NAME <br /> MI Laa1 PHONE NUMBER <br /> First <br /> l E-MAILAOORESS <br /> BUSINESS NAME 55 �J C '/I I! <br /> Owner Home Address `J <br /> STATE ZIP <br /> city 1 <br /> Owner Mailing Address ' vI� 1 I.pL I ,y N� <br /> Mailing Address City I U�jr �n r. \I (` StQtyl �P <br /> L14 T- <br /> [:]CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMEw AGENCY ❑RESPONSIBLE PARTY l L ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> Accounr lD PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB_DTSC_EPA_ <br /> FACILITY ID# INV# P12-0!5 0 Ibq� - oA-kuw� <br /> prpo2 P(2oo°N4 rM1U7J I <br /> FACILITY FILE: COMPLETE BUSINESS I SITE/PROJECT INFORMATION' ���aaaLLL,,, <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YesNo <br /> IS this an EXISTING PrOjeCt LOCATION but a NEW SCOPE OF WORK? <br /> YEs LY] No <br /> BUSINESS/FACILITYISIT91 ll9.l§fr;fINAME {�Q.1 AMIn1 IJn�� <br /> T ff((��j1''�„JJ ifl IV '1I" �`1 ,I(r1'.1/�� C� �/�'I ,(/�J/'/' r SUITE# BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LOCATION `�_n Vi k7[, r/IAV fivI 11 o <br /> e1A'-•, SLI STATE ZIP <br /> CITY CjG {2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> KEY1 KEY2 <br /> Attention:orCare Of(optional) <br /> Mailing Address/f DIFFERENT from Facility Address <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ett if Billing Party is different from Property Owner of-Responsible Party identified above. <br /> Attention:Grunts Of (optional) <br /> BUSINESS NAME <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> Ar unrrAnGaess for fees and charges <br /> WNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Olvner,Opemfor,Anlbariurl Agen(,or Aespsusible Party and I acknowledge that all PERny t at all <br /> PENAtTTES,ErvtoRCs,Vervr CTTnRCFsand/or Hourstr CFIARGSS associated with this project will be billed to me at the address idenfified above as the ACeoUM'ADD,BU,for also certify that <br /> information provided on this application is true and correct;and that all regulated activifies avgl be performed in accordance sibl all applicable SAN JOocate C n ddress,I <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located a .E1„on as it <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE O 213 <br /> is available and at the same time it is provided to me or my repl'esentn i Jn IA,I -!/��' -SIGNATURE APR <br /> CP .IYrllT�l y l rr•Ti Sq <br /> APPLICANT NAME(PLEASE PRINT) ENVIFI At UNTV <br /> TAX ID P fEALTH OMEN rqL <br /> TITLE <br /> Approved By Date Aacoundng DRice Praceeaing Completed ey <br /> Data <br /> RECEIPT# CHECK# RECEIVED BY Wo <br /> nP AN PE <br /> SITE MITIGATION_ AMOUNT PAID DATE <br /> /OAF/IPAYMENT PAYMENT'TYP/E IJD�� 4/..FFJJ� <br /> FEE:S 7 / <br /> 7S 'l <br />