Laserfiche WebLink
San Joan County Environmental Health Department <br /> « >'>' GREEN FORM <br /> DATE Z /�� MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> SHADED•- END a ONLY OWNERIO# <br /> dl�oo CASE UNIT IV <br /> OWNER FILE:COMPLETEPRrOPERTYOWNER/RESPONSIBLEPARTYINFORM9IIMIY- cNE(911 NERCurtaEMnroNnLewirREHD [L}� <br /> r8usmusNAME <br /> ER NAME PCI(' ��I j <br /> Firsf <br /> MI Last PHONE NUMBER <br /> EMAIL ADDRESS <br /> O A,rr•.ILEx y AAALPAddrese 1 11 rV /4 <br /> STATE ZIP <br /> City <br /> Owner Mailing Address So 0u "f R i A L a.\)-- <br /> state ZIP <br /> Halling Address City ROC L.IN <br /> ❑GOVERNMENT AGENCY ❑RESPONSIBLE PAM <br /> El OTHER <br /> ALCORPOMTION ❑INDIVIDUAL v❑(PARTNERSHIP <br /> SITE MITIGATION_ENVIRONMENTAL Ag5ESI M!NT2Y,VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDM INV# ACCOUNT ID PRMI Rost ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DISC_EPA_ <br /> AR 5, <br /> 8 7 f <br /> FACILITY FILE: COMPLETE BUSINESS/SITE!PROJECT INFORMATION: <br /> IS thjs B NEW PfOf eCt LOCATION ROL PfBV1OUSly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes No ❑ <br /> YES ❑ No ❑ <br /> IS IhjS en EXISTING Prof Got LOCATION but a NEW SCOPE OF WORK? <br /> BUBINESSIFACILITISREIPROJECT NAME S-r( <br /> l• SUITE# BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LOCATION Ce [ I <br /> 7 STATE LP <br /> an S TOCK C <br /> BOARD OF SUPERVISOR DISTRICT <br /> LOCATION CODE KEv1 KEYZ <br /> Attention:or Care Or(OPOOMI) <br /> Mellllsg Address OOrFFERENT#Pm FaclW Address <br /> STATE ZIP <br /> Mating Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or espoc ssrebl PaOf t <br /> Identified above, <br /> BUSINESS NAME ALf Ir U <br /> A f PRONE <br /> Mailing Address A �3 nl• ti1�ff 1 q �� - q� I�'9�1 VI <br /> STATE LP ^ <br /> CITY 1N lT6. PA V `_`. y- C A 41 <br /> 1 ` G- OWNER FACILITYIBusiNESS HIRDP TY BILLING <br /> A ftrQMA00RE55 <br /> for fees and Charges <br /> Andwri rdA e r or Rm meribfe Pary and I eclmmv ge t all PERMIT FEFS, <br /> BILLING Amp f_ompLANCE ACKNOWLEDGMENT: h the mdemigned ApplicanA mrti(y Ibet t em the Dann,OPeruma R^ P <br /> PENALTIES,ENFORCEafEM CHARGES and/or HOURLY CHARGES estocialed with dda project will be billed to me at the address identified above As the ACCOOMAneR£SS for dila Bite 1 oleo certify that eB <br /> ioforeation provided on this application is nue and correct;and that all regulated activities will be perforne diem.accordance <br /> %ithble all applicable <br /> the AN OAQUINcated Chou miler rata tylnce Codeadrd of <br /> Smndards and STATE ender fFEDERALaM and laws and Re porta, nt.d other <br /> Me malevirmommd Ownn,Opemmn 6 P <br /> ry project <br /> hereby authors the release of mY and ell rcWb,reports,and olber enviranmemel mseemmt inforvmtion to SAN JOAQIIIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as sam m it <br /> is available and e1 the same time it is provided <br /> to m•eAtor my re rnenmdva <br /> APPLICANT NAME(PLEASE PRINT) J IIV\ REEN SIGNATURE <br /> TAX ID# <br /> TITLE Sp, 1I <br /> I—N o� , IECT ���aloR� <br /> 1` f"C1�fRw Accounting Office ProWeaelR Completed BData <br /> Approved By DeU <br /> SITE MIT�IGAnTION AMOUNT PAID DATE OF PAYMENT PAYMENTTWE RECEIPT# CHECx# RECEIVED BY 2gSa <br /> FEE:$ / ,0 <br />