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SAN JOi& COUNTY ENVIRONMENTAL HEALTH DECENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> E�E4 <br /> r' SITE MITIGATION & LOP <br /> SHADED AREAS fOR EHD USE ONOWNER ID# D/.S 0 D/y 1/'J CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTYIOWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNERS CURRENTLY ON FILE W?H EHD <br /> PROPERTY OWNER NAME rMoyl /► A A` t <br /> FIRST Ml LAST PHONE NUMBER <br /> BUSINESS NAME E-MAILADDRE S <br /> erVtesore h }elrla ���• <br /> OWNER HOME ADDRESS !) <br /> L4;4) )- wl <br /> CITY C' 1 STATE ZIP <br /> OWNER MAILING ADDRESS 7 `JI IT/� <br /> MAILING ADDRESS CITY $TATE ZIP <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY <br /> ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENTi VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA <br /> ,goo`MI6 K0 113 U h 3 <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PR T ORMATION: C't j 32 7 j <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES,f NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO4— <br /> BUSINESSIFACILRYISITEIPROJECT NAME T 4 1 _ <br /> SITE ADDRESS I PROJECT LOCATION / ��` I '� I' ' SUR # BUS ESS PHONE <br /> V U X [7 <br /> Clrrb _ )3 <br /> \ -� /� STATE ZIP J <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> A- <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS n ATTENTION:ORCARE OF(OPT10 LJ <br /> MAILING ADDRESS CITYC\_ H(, ^ -1cSTATE ZlP _,zq <br /> SIC CODE APCOMMENT: <br /> #1 63Z•- � � <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) �1\ie <br /> MAILINGADDRESS PHONE /Q --V1M <br /> CITY STATE ''ry�✓OqQ o�[' <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS THIRD PARTY 13I1-61(1�J� <br /> BILLING AND CONIPLU NCE ACIQNOWLMNIENT: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Parlp and I acknowledge that all PERAHTF£Es, <br /> P&VAL77E4,ENFoRczimw CHARGES and/or HOURLY CHARGES associated with this project will be billed to meat the address identified above as the ACCOUNTADDRESS for this site. 1 also certify that all <br /> informafion 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 REGU ATIO:,& As the undersigned Owner,Operator,Authorised Agent,or Responsible Part),for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENymaNNIENTAL HEALTTI DEPARI11ENT as soon as it is ayailable <br /> and at the same time it is provided to me or my representative. _ / <br /> APPLICANT NAME(PLEASE PRINT) EP IAO Y D j7 r •'fir.• SIGNATURES <br /> l«1���� / C���111 ���l- I I i L.__. 777 LLWtt�i lll�i� � <br /> TITLE 11�I� T�e►�GIY��` Tax ID# <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY PATE <br /> SITE MITIGATION 1:12 <br /> D DATE OF PAY/HENT PAYMENT TYPE RECEIPT# CHECKr,# RECEIVED BY WORK PLAN PE <br /> FEE:S J� I/ <br />