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San .loaquin County Environmental Health Department <br /> DATE &TER FILE RECORD INFORMATION IFR" GREEN FORM <br /> f�( �l` � SITE MITIGATION & LOP <br /> SHADED AREAS FOR EMD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLO�WING PROPERTY OWNER /NFORMAT/ON: CHECKIIF OWNER CURRENTLYONFILEwITH EHD <br /> PROPERTY OWNER NAME I (% (..IJ�J <br /> First `J /VtiJ MI Last PHONE�NUMBER <br /> BUSINESS NAME T� E-MAIL ADDRESS <br /> v �v.. C. o . �- <br /> \ <br /> owner.F Orn Address <br /> t, t� �� <br /> City T TE ZIPr� r <br /> Owner I�@Iling Addre <br /> Mailing Addreej�Clty State Zip <br /> CORPORATION Ld. INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION T_ENVIRONMENTAL ASSESSMENT VVOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> -]� <br /> F�FAOILIT-YD# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC_EPA_ <br /> �l 3� PPD 5 g <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 'y <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUST SS/FAFILITYAIT"NQ�IEj _ ` P i (� ..1 `lA 0. % <br /> 1 K. J� \J �J:� \ R W <br /> SR ADDRESS SUITE# BUSINESS PHONE <br /> .u� S b� <br /> CRY n STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT /S( LOCATION CODE �/ KEY1 KEY2 <br /> Mailing Address WD/FFERENTfrom Facility Address ! Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> Ifft <br /> P PN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME AttenUon:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> AccouNTAooREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEmEA7-CRARGES and/or HOURLPCHARGES associated with this operation will be billed to me at the address identified above as the ACCuo'A7 ADDRESS 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 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 facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENk as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> _ J <br /> APPLICANT NAME(PLEASE PRINT) �1 ` �1!,t) SIGNATURE <br /> TITLE C1 (Nl��t TAX ID# <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATIONAMOU�NNyT PAID 11 <br /> DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK#[.�/ RECEIVED By WORK PLAN PEE/ <br /> FEE:$ V" t w-" "Jb C t- �L3/ c J L <br />