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San J�,Iiirtulin County Environmental Healff. 1partment <br /> DATE M ER FILE RECORD INFORMATION RGREEN FORM <br /> 5 O 75 SITE <br /> 'MITIGATION& LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE if WJ UNIT■T '`\ <br /> V <br /> OWMER FILE:COMPLETE THE FOLLOWING PROPERTY OWNER/NFORMAT/ON: cl;lF OWNER CURRENTLYONFILE WITH EHD <br /> PROPERTY OWNER NAME ( 1 <br /> First MI Last PHONE/NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> S'! CA 1p �G <br /> Owner Home Address <br /> City STATE ZIP <br /> r <br /> Owner Mailing Address <br /> Mailing Address City S I Zip <br /> JGf-A PAfZ ` <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY-HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# - ACCOUNT IDPR RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA_ <br /> AR.0034 <br /> FACILITY FILE COMPLETE THE FOLLOWING BUSINESS/FACILITY/SITE/NFORMAT/OM <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IA <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO /A <br /> BUS IN ESSIFACI LITY/SITE NAME <br /> 213 <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 2106 viesr i've <br /> CITY STATE ZIP <br /> ST ac icTaj► A q 72,C) <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 FKEY2 <br /> Mailing Address ifD1FFERENTfromFacilitteAddress Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> 7[ <br /> SICGODE � APN# COMMENT: I�.EliS� '��D Alt- Cv►L'kG5►�'r' cater AaD L�iw•+L+ <br /> �C> - 92- %L.At E.�o.� map (>Z�Q , � �tx�"�c. C 37-d <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention: rCare Of (optional)' 151;1*� 0 <br /> .s?AnlT �an t Tib& :S�i�;r,c: c jt�c. Ld ^)e <br /> PHO E <br /> Mailing AddressL'��� �� /� � W �' ��♦ r d r <br /> akOr� <br /> CITY STATE zip <br /> AccounlTApoREss for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING .23 <br /> BILLING AND COO'IPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Olwrer,Operator,or Authorized Agent of this Business,an ac owe ge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated iiith this operation will be billed tome at the address identified above as the ACCOLIVTADDRESS for this Site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance ivith all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAI7ENT as soon as it is available and at the same time it is <br /> provided to me or my representative. �! <br /> APPLICANT NAME(PLEASE PRINT) Sf�a„)� "� SIGNATURE <br /> TAX ID <br /> TITLE <br /> A t <br /> Approved By Date Accounting Office Processing Completed By Date l 1(-,113 <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK 0 RECEIVED BY WORK PLAN PE <br /> FEE: <br />