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San Juin County Environmental Health epartment <br /> DATE ;� l MJ TER FILE RECORD INFORMATION SWR" _ GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHAD DAR e FOR EHO USE ONLY OWNER ID# 3-73 CASE III UNIT IV <br /> OWN ER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWN ER/NFORMAT/ON.- CNECKLF OWNER CURRENTLYONntewnN EHD <br /> PROPERTYOWNERNAME C Q L4 A r � , <br /> 1 0 �`an Jas t r7 t04 � - 2 jZ <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME <br /> ColAE-MAIL ADDRESSrtr o-(+ Sin haw N;t ��okevv I,tkrsseh kwasson 5 0 <br /> Owner Home Address ✓• O r <br /> 222 )Ec,s T Web'e A V-r 675 <br /> city nn <br /> STATE <br /> Owner Meiling Addre� 1 -79 E �+ ZIP 5 O <br /> . S�d7�Ts f1✓'e. t� <br /> Melling Address City .5 1-06�;?a <br /> staA nP 5205-1r2�Q <br /> CORPORATION❑ INDIVIDUAL El PARTNERSHIP❑ FEDAGENCY❑ <br /> OTHER <br /> 817E MITIGATION_ENVIRONMENTAL ASSESSMENT_-VOLUNTARY CLEANUP_WATER QUALITY_NW PIPELINE INVESTIGATION_LOP_ <br /> FACILITYID# INV# ACCOUNT ID P O# =A�SSIrGNEOEpLEAOAGENCY:EHD A- RWQCB_OTSC_EPA_�� 02- 531�24`t <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE/NFORmwmw <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES,(f No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No�] <br /> BUSINEssiFACILITY/SITENAME 0 1 1 -— i - ben re / <br /> SITEAODRESS / rs Q � /'` / //11 ` <br /> (� '✓l N. / -r�e r SUITE# USIN PHONE <br /> Cml� {{ a 66 -3220 <br /> 5'7-0 Ic ipN /, '45Zo2-Z11l <br /> BOARD OF SUPERVISOR DISTRICT LOCATION'— KEY1 KEQ <br /> Melling Addcase KD/FFERENrfhwo FeC//ltyAdiakwas Attention:orCere Of I'Cubonal) <br /> Melling Address City STATE ZIP a <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifledabove. ! <br /> BUSINESS NAME <br /> on Jor E q r r-k ( e c 1, n o l 0 1 Cj e Attention:orCere Of(D,oaonaq <br /> ftl e x rT + <br /> Melling Address Dew <br /> CITY /�, P NE <br /> Lf8- F✓atn \oZe T Gf. sTe I ZC1°i 23Y-cls/e QL <br /> STOe�, ��1� STAT ZIP <br /> Zo6 <br /> AGCOVATADDEEm for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PFAnLI/E.q ENFORCE,MENICILIRGET and/or HOL'RL YCHg E.S associated with this operation will be billed tome at the address identified above as the A(Y UC'A'l'ADDREw for this site. 1 also certify that <br /> all 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 properly 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 DEPART? T as scan as it is availabl and al the same time it is <br /> provided N tomerepresentative. <br /> A ) <br /> APPLICANT NAME(PLEASE PRINT. ! �_ _ L/ J-C <br /> TITLE ,5SIGNATURE <br /> . +?rl� TAX ID#j <br /> Approved BY Dat. Acewrdina OIRDa Proeaaal CDmplwd BY Dab <br /> SITE MITIGATION AMOUNTY P/AID DAT OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVE BY WORK PLAN PE <br /> � Z�.tr G� S <br /> �llz9n i <br />