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RECEIVED <br /> San Joa vin County Environmental Health D'flbartment <br /> cc �+ GREEN FORM <br /> DATE ApR' q 5, 201-2 M ER FILE RECORD INFORMATION > <br /> ;.a!�E MITIGATION & LOP= 59 is aa6 41712 UNIT IV <br /> SHA e7�Ar•�L�C�p��1 C �WNERID# GASE# 99*00&474Z <br /> Q�ry I'�7EWCES CHEGNIF OWNER CURREMTiYONFICE WITH END <br /> OWNER FIL : OMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: <br /> PROPERTY OWNER NAME ` -�— <br /> First Mf Las! PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME r- <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address _ <br /> t: <br /> Mailing Address City State Zip <br /> J✓� ASA3 7 <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER lel <br /> SITE MITIGATION ENVIRONMENT L SS SSMENT_VOLUNTARY CLEANUP—WATER OUAL[TY_HW PIPELINE INVESTIGATION_IAP <br /> FACILITY ID# INV# CC UNT PR RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB_..-r DTSC_EPA <br /> �- a4- 1459 <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY SITE INFORMATION: <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No pi <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILrryiSITE NAME - / <br /> JJ # 1p <br /> SITE ADDRESS ++ II SUITE# BUSINESS PHONE <br /> �,z 1Z 9�+�RT14 Cltt..tt``b2N St <br /> CITY STAIE ZIP <br /> air <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEYZ <br /> Mailing Address ifDIFFEREA/T from FacilityAddress Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE Iffffa <br /> 632do 1 <br /> + THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (o nal) <br /> Mailing Address 7 PHONE <br /> o �, b &,l 6-33(Q <br /> CITY STATE ZIP <br /> t CA-- Cl St, <br /> AC.G.0.1/NrAvQ8Ess for fees and charges OWNER FACILITY/BUSINESS THIRD ARTY BILLIN <br /> RILLING AJND COMPLI.INCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or AIwlrori;ed Agent of this Business,and 1 acknowledge that all PER.IfIT FEES. <br /> PE,V.rt T1ES,EfVFORCEVEhT CHARGES and/or 11011RLYCHARGES associated with this operation will be billed to me at the address identifled above as the cl crouNTADDRESS for this Site. I also certify that all <br /> information prorided 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 property located at the above faeifitylsite address,r hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OEPARTMENT as soon as it is available and at the same time it is \ <br /> prodded to me or my representative. J� / <br /> APPLICANT NAME(PLEASE PRINT) f A.n� SIGNATURE ��� <br /> TITLE S f A� L EPP-os LTlrR'C /AANAGE� Tax ID#II Z1(.11 <br /> y <br /> Approved By Dale Accounting Office Processing Completed By Date ✓ <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ .35-02 <br />