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From:STANTEC 9168610430 07/0812013 15:05 VLa�tOJ <br /> JUL 08 2013 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE 7/gZ, MASTER FILE RECORD INFORMATION"CWFR" IT MENTAL <br /> i 6 XVS�P41Hfi?N <br /> SHADED A"AS IDR EHC USE ONLY OWNER IDB cASEA .. UNIT IV ENT <br /> OWNER FILE.COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOwMtxtSCVRREVrLYO�VnLEW?M EHD©/r <br /> PROPERTY OWNER NAME ( <br /> FIRS r MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADORESS <br /> "7- �l ev� %c. <br /> OWNER HOME ADDRESS <br /> CITY STATE ZIP <br /> OWNER MAILING AODREss <br /> MAEJNO ADDREas CITY $TAT ZIP <br /> !7 TAP <br /> L]f'GORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPOHSFaLe PARTY ❑OTHER <br /> SITE MITIGATION /ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP—WATER QUALITY,HW PIPEUNE INVESTIGATION—LOP T <br /> FACILITY ID0 1104 AccouwID PRO/R(2-0AaatGN�O R"RIOYEE' LEI(D(�IiEENOY EH rtiWi�CBf�,,DISC,, .F � <br /> FACILITY FILE:COMPLETE BUSINESS 1 SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [9-- <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES lI? NO ❑ <br /> BUSINESSIFACILtTY/SITEIPROJECT NAME <br /> SITE ADDREa9f PROJECT LOCATION SUITE BUSINESS PHONE <br /> uo Ct w L <br /> CITY STATE ZIP <br /> 64 2,z020 <br /> LlBOARD OP SUPERVISOR DIaTfw'T - LocATION CODE KEY'l .. - KEY2 <br /> MA1L010 ADDRESS,IF DIIFERENT PROM FACu"ADDReaS ATTENTION:ORCARE OF(OR110VAL) <br /> lAAiLwo ADDRESS CIT' STATE ZIP <br /> Ef� <br /> APN A COmRENr: . <br /> THIRD PARTY BILLINO INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> SuaM/m NAME : CARE OF(OPrQHL) <br /> v / � J ` woR <br /> S7AILitO ADDRESS <br /> PHONE <br /> SD 17 ore e &d7 00 140-1-l0/-0406) <br /> CITYh c4v d4Vtl- G 4-TE zt S(a 70 �,.0 <br /> ACCOUNT ADOREaa TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLINGI? <br /> RIL I ING AND CONIPLSANCE ACKNOtti LfDGMENT: 1,tlfe undersigned Applicant,certify Rut I am dw 0—ter,Opem6tr,AulhorizedAgent,ar Responsible Party and I acimowkdee that all PERAUTFEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOVRI.Y CHARGE,P associated with this project will he billed to me at the address identified above w the ACC'OUNTADDRESS for this site. 1 also certify that all <br /> information provided on Juin application is true and correct:and that a0 regulated activities wi11 be performed in accordance with 90 applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Omvter,Opoator,Autho ized Ageut,or Respwtrlbk Party for the project located above under facility/Ate address,I <br /> hereby authorize the release of any and a0 resulM reports,and other environmental assessment information to SAN JOAQUIN CO ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avaitable <br /> and at the sante time it is provided to or my representative. <br /> APPLICANT NAME(PLEASE PRMTJR yOu y)1 !.1 SIGNATURE �,�,� /�A L`�✓ _ s_ .—_ <br /> TITLE �f 17 e✓ n�`�G t ✓i�(/� TAX IDA <br /> APPROVED BY DATE ACCOUNTING OFFICE PROO2 P40 OPNPLETED BY DATE y.���" <br /> SITE MITIOATiON AMOUNT PAID - DATEOFPAYMENT PAYMENTTYPE RECEIPTS CHEOX0 RecoweDBY �Ut <br /> I'$If <br /> FEE: _ _ _ <br />