Laserfiche WebLink
San 0luin County Environmental Healthwartment <br /> DATE T-5-12- MASTER FILE RECORD INFORMATION NNMFRII GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED ARMS FOR EHD USE ONLY OWNER ID# ,� C� �� CASE# �^ 24 UNIT IV <br /> OWNER FILE g E <br /> EDTWRxL PROPERTY OWNER f� �ow�Nen a EwR>wrFwEvweF E"D � <br /> PROPEMY DWNER NAME -r S \LCT —63 <br /> First MI Last PHONENUMBER <br /> EMAILAODRESS <br /> BUSINESSNAME r, <br /> Osamer Hone Address / <br /> Dlt SUM l-�h..� <br /> City STATE ZIP <br /> l_epr�1 C4�t �1 s 2.4 D <br /> OWner Malting Address <br /> MallYq Address CRY stab Zip <br /> CORPORATION❑ INDIVIDUAL❑ y PARTNERSHIP El FEDAOENCY❑ OTHER n <br /> SITE MITIGATION_ENVIRONMENTAL AUMSM!"T/y VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR RO# AaslaNEoEMPLOYEE '.LEAD AGENCY:EHD�RWQCB_DTSC._EPA_{ � <br /> FACILITY FILE CdwLErE-rWRXL0fflM BUSINESS/FACILITY/SITE C NTIOr <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? VES No ❑ pp <br /> m <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? VES ❑ No T <br /> r <br /> BUBINE881FACILm/SRENAME <br /> BffEADORESS L� f� SURE# B=NMSPHONE <br /> Cm, STATE LP C <br /> 2 c� <br /> BDARD OFSUPERVISOR DISTRICT a .LOCATION CODE z "KEPI -K� <br /> Melling Address WOIFFERE 1T8enFIPO 'Adld'owa Attention:arCare Of <br /> Meiling Address Csy STATE ZIP <br /> SIC CODE .APE# Qy7 _ qo _o7 . COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINEss NAME Athmidar.wCare Of(apelarsdO <br /> Mailing Address PHONE <br /> STATE ZIP <br /> Cm <br /> ACCOURE forfeesand Oaarges ()WEER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BTUING AND CQMTLIANR ACKNOWLEDGMENT: 1,the undersigned Appficanb certify that 1 am the(weer,Operator,or Autboriwd Agent of this Business,and 1 acknowledge that all F£RDDT FEES, <br /> Pl9Id6T/ES,ENFNRCEMENTCHANCES and/or HougR YCHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. I also certify that <br /> all 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 ember <br /> Standards and STATE saber 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 environmenml assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the more time it is <br /> provided to me or my representative. _ <br /> APPLICANT NAME(PLEASE PRINT) / p SIGNATURE ��� -�$- <br /> TAX ID# <br /> TfTLE�y.:.tf Pe J�%asr CSG JCA usa� rl _ <br /> Approved By Oab Ammunting OlNoa Prooem <br /> Saing Copleted By Data <br /> SITE MITIGATION A'M�ouNNT�PJAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN�'PE <br /> FEE:,S 3-7 GJ6� <br />