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San Juin County Environmental Health L,widartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# `` UNIT IV <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY/NFoRMATioN. CHECKIFF OWNER—CuRRENTLYONF/LEWITH EHD <br /> PROPERTY OWNER NAME -FYA rJ 1--- - <br /> `/ � / i V D ) o <br /> First MI Last \PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> t) i nD l U k 2 b C G ) <br /> Owner Home Address (oil <br /> N r tNG <br /> City STATECISLA-b CIJ4 ./A ZIP /j� <br /> v!! ^ <br /> Owner Mailing Address V I/6_ <br /> Mailing Address City state Zip <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATIONXENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY I D# INV# ACCOUNTID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB DTSC_EPA <br /> 1RO- P15 o l,�K u ko <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ,g❑ No ❑ <br /> IS this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES /_7 No ❑ <br /> BUSINESSIFACILITYISITEIPROJECT NAME e— <br /> j `^ D` A <br /> (J <br /> r 1 ` -FR ( 0 <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 1011 KY-7 w 72Y-Liv <br /> CITU S ti STATE ZIPq,526, <br /> l <br /> ESOAR.OF SUPERVISOR DISTRICTO I LOCATION CODE 0 ' KEY1 KEY2 <br /> Mailing Address ND/FFERENTfrom FaellllyAddress Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> 11 / 3-;Lg0-/3 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME ty <br /> t�, (`��! � V N` Attention:orCare Of (optional) /C`_ V -p, <br /> 101—Ir <br /> Mailing Address \� v'�/L/l� PHONE q�S l�: (n <br /> CITY �-t )o oto re STATE ,{ ZIP tfY�7r l l <br /> ACCQUNr- DDREss for fees and chargee CC�WNE FACILITY/BUSINESS THIRD PARTY BILLING <br /> MILLING AND CQMPLIAN(:E ACKNOWLEDGMEN"1': 1,the undersigned Applicant,certify that I am the(Mater,Operator,Authorized Agent,or Reapnacihle Party and I acknowledge that all P@RAf77'FEES, <br /> PENALTIEv,ENFORCEAfENTCHARGES and/or HOURLYCHARGES associated with this project will be billed to me at the address identified above as the ACCOUM'AHDRESIS for this site. 1 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 COUNTv Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENV IRONM ENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) t-SIGNATURE <br /> TITLE //TAX ID# <br /> Approved By Date Accounting Office Processing Completed By Dete <br /> SITE MITIOA AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WARK PIAN PE <br /> FEE:$ }Nl TY`1tF <br />