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�i <br /> San jJ:--L+uin County Environmental Health p-nartment . <br /> GREEN FORM <br /> DATE �-7MfER FILE RECORD INFORMATION SITE MITIGATION & LOP <br /> S <br /> w. CASE# 5Q� Inst Z UNIT IV <br /> AHAOED AfFJ18 F_OR EHDUII Ut1�.Y OWNERID# <br /> C..-c,,,r OW ER CUARFNTLYONFILE N7TF/EHD'� <br /> OWNER FILE:COMPLETE THEFOLLOwiNG PROPERTY OWNER INFORMATION.' r <br /> PROPERTY OWNER NAME - <br /> Firsf AN. Lest PHONENUMBER <br /> E-MaaAODRESi <br /> BUSINESS NAME - <br /> 5{ <br /> Owner Home Address <br /> _ STATE ZIP <br /> CRY <br /> rG 1- Jff� <br /> Owner Mailing Address <br /> Mailing Address City State <br /> 0ORPORA7lOtfYlJ INDMDUAL❑ PARMFMHIP❑ FEDAGENCY❑ OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT__)�VOW NTARV CLWMUP WAVER QUALITY_HW PIBELINE jNvzBT16ATjoN _LOP <br /> FACILITv iD# INY# AccouriT ID PR#!RO# ASSIGNED EMPt OVEi LEAD AGENcr EHper—RWQCB___.;DTBC.—'EPA- <br /> 3E i l�&6 <br /> FACILITY FILE COMPLETE THEFottow1NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a New Business LOCATION not prediously regulated by the ENVIRONMENTAL_HEALTH DEPARTMENT? YES ❑ IVO'❑ <br /> is this an ExisTlNG Business LOCATION but a NEW TYPE of regulated Business? Yt s ❑ No <br /> tj <br /> BU3tNEsWFACILny1Stre NAME <br /> SrrEAnoRm - SUITE# R S1NESSPHOt(E <br /> CfTy - .. STATE Zip r <br /> BOARD OF SUPERVISOR DITMWT LOCATION CODE .. KEYS .�i: .. KE,2 - <br /> ,i <br /> Mailing Address NOIFFERENTh+smFaellKyAddrlaxp AHmAlon:orCare Of ropflonw). <br /> Mailing Address City STATE Zip , <br /> SIC CODE APN# ' COMMEKr <br /> ii <br /> ;i <br /> THIRD PARTY BILLING INPo. Complete ff Billing Party is different from Property Owner.orFacility Operator identified above. <br /> BUSWEssNAMEAttention:arCare Of(opLbnal) <br /> s Mailing Address PHONE <br /> Rim0� <br /> CTTY - - STATE ZIP <br /> S ►-� tut,i- <br /> BCCOAN L9for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING ANCOhtrLIANCE ACKNOw'LEDGPIENT: I,the undersigned Applicant,certify that.I am the Owner,Operntar,or Authorised Agenr of this.Business,and I ac at all PERaurF <br /> D s, <br /> PF.lVALTrEs EvrORcmtrAT'CHARGEs and/or HOURLY CHARGEE assoclated ivith this operation Will be billed to me at the address Identified above as the ArcomvTADDRtSS for this Site. I also certify that <br /> at]information provided on this application is true and correct;and that all regulated activities will be performed In accordance with all applicable SAI'I JOAQUIN Cotlm Ordinance Codes ondlor . <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the nndetsigned owner,operator, or agent of the property located at the above fadlify/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to'SAN JOAQUIN COUNTY ENVIRONMF,NTAf HEALTH-flEP TMF.N1 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)&',y t+yt�3JbcP SIGNATURE <br /> TAX ID <br /> TITLE `� <br /> A proved B Date Accounting Oltl a Processing Com leted B Dat- - <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYME#TTYPE- R_ ECEIPT# .CHECK# RECEIV Dl3Y WORK PLAN PE <br /> f FEE: <br />