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SAN .IOWIN COUNTY ENVIRONMENTAL HEALTH CORTMENT <br /> DATE �0,� r MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> J (D SITE MITIGATION & LOP <br /> SHADED AREAE FOR END UBE ONLY OWNER ID# CASE# S2oo64L� UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK a, aOidwels CuRREAD rOH,RE HTrH E H D <br /> PROPERTY OWNER NAME C, / 0/Lz &3.1 6 <br /> FIRST MI- LAST PHONE NUMBER <br /> BUSINESS NAME ^ E-EMIL ADDRESS <br /> OWNER HOME ADDRESS C <br /> Dm -TV-0- B hp <br /> OWNERMAILINOAOORE88 <br /> MAILINGADDRESSCm \� STATE LP \\ <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP VERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY NW PIPELINE INVESTI'G'ATION_LOP <br /> FAcam ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB Y-DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> ISTHIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> ISTHIS AN EXISTING PROJECT LOCATION/,BUT A NEW SCOPE OF WORK? YES [-INo [IBUSINESS/FACILFI `./ <br /> YISTTEIPROJECT NAME I .s L4 C&SS J1 NAt <br /> SDE ADDRESS/PROJECT LOCATION ` V�' 1�' SURE# BUSINESS PHONEE <br /> obw 7A 1t� k283 -11 -22 <br /> Cm � STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT G� LOCATION CODE (J3 KEYT KEY2 l� <br /> MAILING ADDRESS,IF DIFFERENT FROM FAcLrrY ADDRESS ATTENTION:ORCARE OF(OPTTOHALJ <br /> MAILING ADDRESS Cm STATE ZIP <br /> SIC CODE APN 2 (/� ZZ COMMENT: <br /> �J <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME �1/ I/ .. .�, `r - ATTENTION:ORCARE OF (OPTIONAL)Toe- <br /> MAILING <br /> OPTIONAL) Ue- <br /> MAILING ADDRESS J v J(/• �� C•/l�-T/. (I`- PHONE 3�(1a`LL SCC I_] <br /> dC ^ ` STATE ZN' <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILffY/BUSINESS❑ THIRD PARTY BILLIN <br /> BILLING AND COMPLIANCE ACKNOWLEDGNIENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that an PERMIT FEES, <br /> PEA:4L3IFS,RNFORCEMEATCHARGES and/or ROLHLPCHARGM associated with this project will be billed to me at the address identified above as the ACCOL9YTADDRETS for this site. 1 also certify that all <br /> Information provided on this application is any and correct;and that an 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,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,repmas,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL TH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to we or my representative. _ <br /> /t A — <br /> APPLICANT NAME(PLEASEPRINT) SIGNATURE <br /> TITLE „� C S� TAXID# <br /> APPROVED BY DATE ACOOUNBNG OFFICE PROCESSING COMPLETEDBY DATE <br /> BITEMITIGAITION AMOUNTPAtD DATE OF PAYMENT PAYMENT TYPE RECEIPT CHECK//# (, RECEIVED BY WORK PLAN PE <br /> FEES P5- 3?s t,_j4 �1 l l N� _I a¢l� Jutur6k a9c�� <br />