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San Join County Environmental Health D-nartment <br /> DATE MASTER FILE RECORD INFORMATION All, GREEN FORM <br /> s"HaogoAR °s o Ous o SITE MITIGATION & LOP <br /> OWNER ID# UNIT IV <br /> CASE# <br /> OWNER FILE:COMPtETEPROPERTYOWNER/RE 1110IBLEPARTY/NFoRMAT/oN. cnECK/FowNERcuaxeNrcroNFaeW/rNeHD � <br /> PROPERTY OWNER NAME �/F W p R /' <br /> First MI 'I'1/ tf 'l O l 3JYI <br /> BUSINESS NAME WVlk I1/� / �� j/ Last PHONE NUMBER <br /> 53CC J/ It„+ E-MAIL ADDRESS <br /> Owner Home Address <br /> City <br /> STATE zipOwner Mailing Address Ob <br /> �0i I /V� <br /> ze I �v N A-Vt7 <br /> Mailing Address Ciry <br /> 4Lc14i-la r.1 B� <br /> Z`P9s1�5- <br /> ❑CORPORATION <br /> EI INDIVIDUAL <br /> ElPARTNERSHIP GOVERNMENT AGENCY <br /> ElRESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION-,ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_ <br /> WATER QUALITY_HW PIPELINE INVESTIGATION_LOP _ <br /> FADILITY ID# INV# <br /> Accounr lD <br /> =ASSIGNE12- A,n�� D EMPLOYEE LEAD AGENCY:EHD�RWQCB_OTSC__EPA_ <br /> FACILITYFILE: COMPLETE BUSINESSU /SIT PROJECT hw RMAT/oN. uW) <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES�l <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? f/Lrry``� No <br /> BUSINESSIFACILITY/SITa�g15nT,NAME YES LI NO <br /> ct,11Tw M3 ftn N leu l-F <br /> SITEADDRESS/PRRI.O'JMECT LOCATI N <br /> I i1n I I� 1261v 6� I'�` "A bUv ,r(�/.I r—� SUITE III BUSINESS PHONE <br /> GITv VVY r'�l 11 �/� <br /> STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT <br /> LOCATION CODE KEYT <br /> Mailing Add reea ifD/FFERENTfrom Fec!/ltyAddress KEY2 <br /> Attention:orCare Of(opt'on. <br /> Mailing Address City <br /> STATE zip <br /> SIC CODE APN# <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ete if Billing Party is different from Property Owner or Responsible Party identifed <br /> BUSINESS NAME above. <br /> Mailing Address Attention:orCare Of (Optional) <br /> PHONE <br /> CITY <br /> STATE 7Jp <br /> 21=04WEAWREss for fees and charges <br /> WNER FACILITY/BUSINESS <br /> BILLING AND COMPLIANCE AQKNG{S1.EDGAI4N'rt I,the undersigned Applicant'certify that I am the Owner,Op¢r010r,Aoflmnzed tgent Or Responsible Pony sold IDapcknowledARTY Bge that PERM➢'FEES, <br /> PENALro",ENFORCEMENTCnARGES and/or IIOURLYCHARGFEv associated with this project will be billed to me at the address ideufitied above as fhC ACCOUNT'ty and Iffi for <br /> information provided on this apphcafion is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN,AWRN C <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized d inAgea or Responsible party for the project located a also certify that all <br /> hereby authorize the release of any and all results,reports and other environmental assessment information to SAN JOAQUIR COUNTY ENVIRONMENTAL a5 E ,L.�and/or <br /> is available and at the same time if is provided to me or my representative. st wAddress,l <br /> nn� '� i__ � 6.Jon as if <br /> APPLICANT NAME(PLEASE PRINT) see hi44TI-rh Mgt t.t R s./ <br /> AP 02201 <br /> SIGNATURE <br /> TITLE S .� <br /> TAX ID it <br /> Approved By nate 'EI--r,,, ENTALNTV <br /> Accounting Office Proeeaaing Completed By <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT Date <br /> FEE: 1�l 417-113 <br /> 'L PAYMENT TYPE/ RECEIPT# CHECZH# RECEIVED BY <br /> S �3 I S � T/Z )3 13Sz.S WORK PLAN PE <br /> VVV �q�p <br />