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San Joaquin County Environmental Health Department e DATEC 1. MASTER FILE RECORD INFORMATION "MFRGREEN FORM SITE MITIGATION& LOP SHADED AREAS FOR EH D USEONLY OWNER ID# CASE# o o LM I UNIT IV OWNER FILE:COMPLETE THEFOLI OwING PROPERTY OWNER INFORMATION: CHECK IF OWNER CUIMENTLYONFIL£WfTH EHD PROPERTY OWNER NAME Firsl _ M/ Last PHONE NUMBER BUSINESS NAME ---- �\ 1"j`,l �5 ; E-MAIL ADbRE33 Owner Nome Address1�WK city S'A.TE / Owner Malting Address �•1 1 1, `��`�� w �� [W.Iffing Address City v 1! siateZIP ^ r t r CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER SITe MITIGATION_ENVIRONMENTAL AssmsmeNT_VOLUNTARY CLEANUP_WATER QUALITY_HW`PtPELINC INVESTIGATION_LOP FACILITY ID# INV# AccoutlriD PR# O# AssIGNeoEMPLOYEE LEAoAGENOY:EHD— _ RWQCBDTSC—EPA s a-27 S�3'7 os�SSg� — FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION.' is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINEWFACILITYISRE NAME SITEADDRESS �t�r� (� i1� `J =TA� 7 6 CITY BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 Mailing Address/fDIFFERENTfrvm FaclNtyAddress Attention:orOare Of(optional) Mailing Address City STATE ZIP SICCODE APN# t 2 f�C �(� COMMENT: THIRD PARTY BILLING INFO:, Complete if Billing Party is different from Property Owner orFacility Operator identified above. BUSINESSNAME 7� .� � ; Attention:orOare Of(optional) Mailing Address �^\1 t\ `� \v � prlcnE 1 1 1 4 CITY �� \^ STATE 1�1 ZIP A¢o9urorAnaeEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operaror,or Awhori.ed Agent of this Business,and I acknowledge that all PEftwT FEFS, PGv.•ILTIFS,FlYFORC&'fEvT CH IRGFS and/or H0URLI'CH.4RGF5 associated with this Operation,hill be billed to one nt the address identified above as file ACCOU(PrADDRES$for this site. I also certify that all information provided on this application Is true and correct;and that all regulated activities will he performed in accordance with all apPIkAble SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDEnAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above I-acilitylsite address,1 hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIF,NT as s:on asi s avafla le and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) 1 L \�� SIGNATURE b v�v il/� , w+ TITLEM \� \ v`t�� TAX ID tF Approved By J llutov Accounting ORIce Processing Comple Lad By Date l SITE MITIGATION I AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE:$�