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San J-ruin County Environmental Health apartment <br /> DATE / �7 ilriWiS "ER FILE RECORD INFORMATION "ivfi',"R s GREEN FORN <br /> SITE MITIGATION& LOP <br /> SHADED.AREAS FORSE_EHD UONLY OWNER ID# CASE#- Cp o bJ,-i '•�•w` ' <br /> =ALTs':COIifPLETETHE FOLLOWING PROPERTY OWN ER/NFORMATm CHEC/t/F OWNER CURRENTLYON FILE WITH EHDF1 <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAILADDRESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City I State Zip <br /> 1;: L <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE i:71T1GAT1O ' MENVIROMMENTAL ASSESSMENT VOLUNTARY CLEANUP—WATER QUALITY�HrJ PIPELINE INVESTIGATION_L07 <br /> A�c,c,oUNTID PR#/RO# Ass'C/r(EjJpEMLOYEE ILED AGENCY:EHD�RWQCBFACILITY ID# INV# ...DTSC EPA ,I <br /> la1TC:_u'i'7::G.G COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORwTlom <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 51 <br /> Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS F Cr CJ J SUITE# BUSINESS PHONE <br /> 9. <br /> CITY SSP <br /> � STATE zip D <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE 1 �! KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrotn Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT:FLrAl�� SZ� L T tLXJ <br /> 7b Srq/--,� @ g d t N <br /> f <br /> THIRD PARTY MILLING:NFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> I BUSINESS NAME _ Attention:orCa �optional)� <br /> IIII v w b 5 l <br /> Mailing Address P NE <br /> b� OqO <br /> CITY /y STATE ZIP <br /> Ch- <br /> Y� <br /> AcA=NTADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING 1 <br /> •BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERmITFEES, <br /> PENALTIES,EAFoRCEAtEAr CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the AccquiyTADDRESS 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 with 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,I hereby authorize the release of <br /> any and all results and enNiromnental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTII9 NT 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) t�/`/�r! 61-6,1 SIGNATURE <br /> TITLE �•S} TAX ID ft �I `7— <br /> r <br /> Approved By Date Processing Completed By Date _ <br /> SITE ITIGATIO AMOUNT PAIDDATE OF PAYMENT PAY6IENT TYPE RECEIPT# CHECK# i RECEIVED BY WORK ppptAN PE <br /> FEE:$ <br />