Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HF_ALTH DEPARTMENT <br /> DATE � MASTER R FILE RECOR D INFORMAY1014 66IV R" GREEN FORM <br /> SITE MITIGATION IY �&r LOP <br /> SJIPA1921ASF.4lE4 Duse L OVINEH IUit CASE M DD b 0 � �� 11 ll �T t:9 <br /> OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION : CNeoiTIFCHwsxrs CuNRervrl. ruvirmerwim El-IDQE <br /> UDDIAn-OWNERNAME <br /> P�� J� I - ,y'lj�t +: Ffl � IaP, c, <br /> R <br /> MI LAst PHONE NUMBER <br /> BUSINESS NAME n A REss <br /> hC.-: ,rl I-: t � ��I'nv' � G(1 ✓ , 150 .� �� 5 ' c: ,rl/., .z '< <br /> OWNER HOME ADDREss <br /> Om I �r zip <br /> STA . <br /> / J� r <br /> OWNER MAILING ADDRESS �- fJ_ <br /> MAILING ADDRESS CITY c-, ( V C— P- Sl'ATE- ZAP <br /> r <br /> ❑ CORPORATION ❑ INDIVIDUAL ❑ PARTNERSH112 .>Eq <br /> GO.VERNMCNTAOENCV ❑ RESPONSIBLE PAP ry ❑ OTNER f <br /> SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP _ WATER QUALITY HW PIPELINE INVESTIGATION _ IAP J\ <br /> FACII.ITV ID Y7 NVlI ACCOUNr ID PRi / RO (J AssIGNED EMPL/OYEE LEAD AGENCY: EH _RWQCB _ DTSC _EPA _ <br /> '{001.1p i 6�6 <br /> FDICILITV GILL: COMPLETE BUSINESS I SITE/ PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED HY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0 NO la' <br /> 15 THIS AN EXISTING PROJECT LOCATIONI BUT A NEW SCOPE OF YVORK'1 YES ' No ❑ <br /> 'I BUSINESSIFAGILITYISITEIPROJECT NAME <br /> SITE ADDRESS I PROJECT LOCATION ��'' , / 1 SUITE O BUSINESS PHONE <br /> �.I CRY / STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOGAT30N CODE KEY1 1 KEYP <br /> MARINO ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS: ATTENTION: OSCARS OF (OPTIONAL) <br /> MAILING ADDRESS CRY STATE ZIP <br /> SIC CODE APNU COMMENT: <br /> THIRD PARTY BILLING INFO: COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME <br /> I r - / ` ATTENTION: ORCARE OF (OPTIONAL) . . ' I1 " <br /> 6 (A <br /> if it <br /> MAILINGAUDRESS PHONE <br /> GUY 8 <br /> oTrA <br /> EA cauNT ARDRcss 1'O III: TEES INDCHAR s OWNER❑ FACILITY/BU INCss ❑ TIRRD PARTY LNLLINGLI <br /> R ICON = Ar _ I Uu, madeitiLrnedApplL rterlfv Real IlntheDie (JIn rdnr( nr1"rAASrm nr ReLyw0hav Pearipalld l lvhll%luloe o 111 Profit Paas. <br /> s 1.,� 7CH1RGF IIdIU H[ t'll.l !' � I mil I 's pr J«I it ill billed tilt,llrlddnsl ldinOlyd RDulr HI -ICCCf_\I I ss fn IIcsR I also cel'IfI Ill II ;1II <br /> affal-Illation It) mId d al Ills aPilliCaliall IS it lie all . mall UMI all I'LouILH I I Iivll O II III 111' I)VI Ra Ill ICUMnl InL ' IIUII 'dl litHk IDR S,N JY,muILN COI STT 011I L: copit illadjol <br /> SIANIMPTYS lial STNI'l and/m FUD - l- L Ovs IU II IL. . :\s Plc lIaIvIsIiiaOI Daum Opelflrul . the laoitef n I II n e Ilii r I IAS B nddvevL I <br /> I - I)l aallallFi7e IIIc rlr ' ce lfand all ltsU1 .1II Ith, atilt allict cll it Uminl. l isselrnl0U ul l in II IU S,W JD,\Qmw Uolem ENY ROLIMENIAL Ilia . 111 UI .II I li laill aYII- Ir nI.IInRIe <br /> atilt DI fllesllnle time It 1.1 Provided In RIe or n17' reprr.ienlnfive, - <br /> APPLICANT NAME (PLEASE PRINT) / SIGNATURE / <br /> TITLE - - TAX ID M / <br /> % L t � { C�d . � lo �. ; ; z� _ 1 - I11G j� OS, I <br /> AYPROVEO pY UATE AccOBNrIIJOOFFICE PROCEssING CGMPLErEO pY DATE a <br /> SITE MITIGATION AMOUNT PAID DA'1E 01' VAYMINI' PAYMENT TYPE RECCIPTn CHERI( Il RECJEIVER BY WORKPLAN PE <br /> FEC: SJ.L ) _T : I / <br /> I IF <br /> r/ . <br />