Laserfiche WebLink
San Juin County Environmental Health leartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> m' SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID#W b D�,D�'�G CASE# UNIT IV <br /> OWNER FILE:CoNfPLETEPROPERTY OWNER/RESPON`SIIBL`EJ PARTY`INFORMATION: CHECKIF OWNER CURRENTLYONFILEW/TH EHD <br /> PROPERTY OWNER NAME V +c't y IL."- "'<"I �Y �( 1 1\1 ` (� C ('.'L_�/ — I <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME �, E-MAILADORES <br /> Owner Home Address <br /> city�, a� � STATE C.1� zip <br /> � <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY IO# INv# ='6Zco;/T:' <br /> PR#IRO# Asspplof QED PLOYEE LEAD AGENCY:EHO RWQCB_DTSC_EPA <br /> x21 -3 <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES Q No ❑ <br /> IS this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE/PROJECT NAME <br /> SITE ADDRESS I PR ECT LOCATION SUITE# BUSINESS PHONE <br /> CITY �w r STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE D ' KEY1 KEY2 <br /> Mailing Address WDIFFERENT from Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE zip <br /> SIC CODE = APN# I I COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME Ay c Attention:orCare Of (optional) <br /> Mailing Add V PHONE <br /> 02 (5 CDO `i�5 - 1co-cao�o <br /> Cm STATE A3 caq tl t- of`P 2�(� S- LP <br /> sot <br /> AccountTADDREss for fees and charges OWNER FACILrrY/BUSINESSHIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOw'LEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Parry and I acknowledge that all PERM/T FI>Ls, <br /> PEA IL T/L.S,EArFORCEAfLAT CHARGES and/or llol!RLY CHARGES associated with this project will be billed tome at the address identified above as the ACCOINTADDRES.S 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.IOAQuIN Cot1N1'Y 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 am and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL 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) a � �J SIGNATURE <br /> TITLE I J; [ /� n .h , <br /> TAx to# 0 <br /> Approved By, 1 Dete J J G'f Accounting Office Processing Completed By Date <br /> SITE MI�TIIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY PLAN PE <br /> FEE:$ ytA� �� 55� —`J /`il <br />