Laserfiche WebLink
:RECEIVED <br /> San Joy lin County Environmental Health�jrtlt� <br /> ?artrrnent <br /> .DATE �` MAr�.7I.ER FILE RECORD INFORMATION �� �J � GREEN FORM <br /> I r `tI <br /> 1- - -`_�l i MITIGATION & LOP--- <br /> 7. <br /> - <br /> SHA p p�,�t <br /> iiCESOWNER ID# CASE# �� I� �� <br /> T 1'll>L'IT( C1ViCHECK IF OWNER CURRENTLYON FILE wam EHD ❑ <br /> OWNER FIL OMPCETETHEFOLLOWING PROPERTY OWNER INFORMATION: r } <br /> PROPERTY OWNER NAME <br /> Firsr M1 Last PHQNE NUMBER <br /> BUSINESS NAME <br /> E-MAIL ADDR ESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address _ <br /> Mailing Address City State Zip i <br /> LV6 <br /> INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER tpl <br /> CORPORATION❑, I <br /> SITE MITIGATION_EmV'IRONMENTAI-AceoaclatFNT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY 1D# INV# -AccbuNT IO PR RO# =ASSIGN EO ElYtP4OYEE' LEAD AGENCY:EHD_RWQ.CB DTSC_EPA <br /> FACILITY FILE COMPLETE THE FOLLOWING BUSINESS I FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEss/FACILITYISITE NAME #21 <br /> ` <br /> SITE ADDRESS " � b SUITE# BUSINESS PHONE <br /> 3212 tJF—M C A-tFbP4%jjAS� <br /> CITY •`_UC {- 7`r ST j _ ZIP <br /> W <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE ' KEY1 Z2 <br /> Mailing Address if DIFFERENT from Facility Address Attention_or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CaDE APN# COMMENT: <br /> 2532 on t <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (o 'oval) <br /> Mailing Address PHONE <br /> a t, c $sot 433 <br /> CITY STATE ZIP <br /> A=uN.LAy2gF_ss for fees and charges OWNER FAClUTY18USINESS _THIRDFARTY BILLIN <br /> $ILLIYG.'\D CO%rPLIA,NCE ACKNDN'LEDGNIE\T: 1,the undersigned Applicant,certif}•that f am the Owner,Operator,or Anthori ed Ager or this Business,and i acknowledge that all PER.trtT FEES, <br /> PEXALT/Es,EAFORC&vfxT CH,lRGES and/or HOURLYCHARGES associated with this operation Will be billed tome at the address identiried above as the A Cr'Ot;,NTADDRESS for this site. I also certify that all <br /> information provided an this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and S'rP.TE andHlr FF,pI;l1,\I.Laws and Regulations. As the undersigned owner,operator,or agent of the properlY located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and emironnlentol assessment information to SAV JOAQUIN CONNTY F,NVIRONPIENTAL HEALTH DEPARTAIENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) LA t�yw,�E �1. SIGNATURE <br /> TITLEt� TAx ID# <br /> ST/1nITEC. pyooiCC�'� ANAc7D— — 216 <br /> Approved By Date Accounting ice Processing Compteted By Oate I / <br /> SITE MITIG <br /> AT <br /> ION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE" � <br /> FEE:$ <br /> tel\ 1 <br /> I <br />