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d <br /> SAN J�)UIN COUNTY ENVIRONMENTAL HEALTH C ^ 1RTMENT <br /> N DATEI — i MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER ID# CASE UNIT IV <br /> OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK IF OMERIS CURRENTLY ON FRE wrNt EHD <br /> PADDERIPPOWMER NAM � rry I I V/ i --50 ( ?a4) 7 <br /> 4117. VI ecTO/ KIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME / � E-MAIL ADDRESS <br /> !n *' a � V( mft C� i 'I{<1 ( Pro ecrS p✓aS5Dn � 5 ' �rI/, d <br /> OWNER HOME ADDRESS <br /> ` S� � S 5 5qa Vberlocch ;n �' sj <br /> G5 ° v, aPyCITY ST c !� ST A LP 5Z %1 Z <br /> OWNER MAILING ADDRESS C/.�l- <br /> 0 W, r kf - <br /> MAILINGADDRESSCITYl � STAT ZIP <br /> 7 c9on <br /> ❑ CORPORATION ❑ INOWIDVAL ❑ PARTNERSHIP GOVERNMENT AGENCY ❑ RESPONSIBLE PARTY ❑ OTHER yy(( <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP _ WATER QUALITY HW PIPELINE INVESTIGATION _ LOP A <br /> FACILITY ID # INY# ACCOUNT ID PR #/ RO # ASSIGNED EMPLOYEE LEAD AGENCY: EH RWQCB _ OTSC _ EPA_ <br /> �d 77 S �� <br /> FACILITY FILE: COMPLETE BUSINESS I SITE/ PROJECT INFORMATION : <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THEENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESSIFACILITYISITEIPROJECT NAME <br /> SITE ADDRESS /PROJECT LOCATION 6 , 0 / / SUITE # BUSINESS PHONE <br /> CITY STS GVL �O ^ STATE ZIP <br /> S 2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE =KEY1 11 Ki <br /> MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS ATTENTION: ORCARE OF (PrIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> 11 SIC CODE APN # COMMENT: <br /> THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME G // T' ( ATTENTION: ORCARE OF (OPTIONAL) <br /> d h / � chn0 0 (@ <br /> MAILINGADDRESS ONE <br /> tt <br /> r rs Zo Z3 , e9 <br /> DIfY T'o c L �a -�� STAT <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNERO FACILITY/BUSINESS❑ THIRDPARTYBILLIN <br /> BULLING AND COAVLIANCR ACKNONLEUGhIENT: 11 the undersigned AppticaraL certify that I am the Owner, Operator, AnlhoritedAgenr or Responsible Parry and T acknowdedge that an PEINRTF Es, <br /> PEVALTIES, EN£ORCEVENT CHARGES and/or HooaYY CHn GES associated with this project will be baled to me at the address identified above as the ACCOOnTADDII 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 JOAQM Coo OpUrNANcs Cores and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and RRGULATIONS. As the Undersigned Owner, Operator, AuthmhedAgent, or Re ponsible Parry for the project located above wofir facility/site address, l <br /> hereby author've the release of airy and all results, reports, and other environmental assessment information to SAN JOAQpLY ConrcmT Eon mosanowAL HEALT=DRP�Aas n as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME (PLEASE PRINT) C�/s E7/v n -r SIGNATURE / /J <br /> TITLE7enLD � Ve- ol rIsI �L TAXIDp q 2l, q " � S <br /> APPROVEDBY DATE ACCOUNTING OFFICE PROCESSING COMPLETEDBY DAIS <br /> SITE MITIG�ATITIIOONN AMOUWPAIO DATE <br /> EE)OFF PAYMENT P ENT TYPE RECEIPT CHECK # RE IVEDBY WORK PIAN PE <br /> FEE. ✓' .CX <br /> Zg <br />