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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> �l SITE MITIGATION &LOP <br /> SHAMED AREAS FOR END USE ONLY OWNER ID#D (��S3�i CASE# UNIT IV <br /> OWNER FILE:COMPLETEPROPERTY OWN ER/RESPONSIBLE PARTY/NFORMATil cNecw fr OWNER CURREWLYONFue WITH EHD� <br /> PROPERTYOWNERNAME / 1- S T I S (?aq)a 7 (- 3 300 <br /> First Ml - Last PHoNENUMSER <br /> BusiNess NAME Ur / ce'J Lel E-MMLADDRESS <br /> Owner Home Address <br /> City I ` V'\ STATE <br /> Owner MailinggJA'Iddtddreas L! <br /> S <br /> Mailing Address City State ZJP <br /> ❑CORPORATION INDIVIDUAL El PARTNERSHIP ElGOVERNMENTAOENCY ElRESPONSIBLE PARTY ElOTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> ./F/ACRm ID# INV# ,t AccouNTID PR#1 RO# ASSIGNED <br /> EMMPLOYEE LEAD AGENCY:EHD._,)tf—RWOOB_DTSC <br /> NY� ;t�m22$G� Aaoo`1'143 �DJ cf�7 JDFf N / <br /> FACILITY PILE: COMPLETE BUSINESS/SITE/PROJECT fNFORMATION: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EXISTING Project LOCATION but NEW SCOPEOF WORK?/ YES No ❑ <br /> BUSINSIMLFACILITYISIEIPRwECT NAME <br /> SnEADDRESS/PROJECTLOCATION2-1 SUITE# BUSINESS PHONE <br /> Cm 11 �G-Ljyt L/�L/ D 11/ S/TLATE ZIP <br /> SIZ�G <br /> BOARD OF SUPERVISOR DISTRICT 6 / LOcAroN COOS d/ KEPT KEY2 <br /> Mailing Address IfDIFFERENTfrom FwAltyAddress Attention:orCare Of(opbmsel) <br /> Mailing Addrees City STATE ZIP <br /> SIC CODEAPN# QTY COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if (lling Party is different from Property Owner orResponsible Party identified above. <br /> BUSINESS NAME .rr"' G dantion:ar are Qf(optional) <br /> L LO"t 6 L) � 2 <br /> Mailing Atltlreae Z PHONE 6ZJ S I —7135 <br /> CM S STATE v I e-(, 3 <br /> Ar4auATADDAM for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BILLING <br /> BILLING AND COAIPLIANCe ACKNGWLEDGNENr: I,the undnSigned Applicant,eertify dant I am Me Owner,Operator,AaM.AtedAgerK ar Respons(dfe Pnrty and t aclmowledge that aU P£RARTFEGT, <br /> PE'MLTI£S,ENraRCEAI£AT CHARGES evdlor HOURCYCKLtGTs associated witls slily projea.val 6n baled ro me et the eddms identified above m(be ALCOUr?AOnR6ee for tids site. l i lw certifv that.0 <br /> information provided on this eppUcntims is true and earrecy and shat all regulated activities will be performed in eccordanee with all applicable SAN JOAQIRN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL laws and Reguladom. As the undersigned Owner,Operator}AethorimA.Agent,or Responsible Party for the project heated above ander faciliyfsite address,I <br /> hereby authorize the release of way and nil results,reports,and other enviroomearal assm ansit information to SAN JOAQUIN COUNTY o ENTAL HEALTH DEPARTNIENT es soon as It <br /> is avaaable and at the some time it is provided tome/or my r presentative. <br /> APPLICANT NAME(FLEASEPRINT) Cbl ' � iSIGNATURE tyil � <br /> r <br /> TmE L TAX ID# <br /> Agxvvetl By Dein A,:Zg Office Processhrg Completed!By Data <br /> SITE MITIGATION AMOUNT PATO DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECE!VED BY W p.N Pu!!PE <br /> FEE:sgc�a 3�cv y—G-IS Erna r 3gs5' � 950 <br />