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San J4uin County Environmental Health�partment <br /> DATE ( q MASTER FILE RECORD INFORMATION `rMFR" GREEN FORM <br /> JLY. ZZ, ZCi <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OINNERID# CASE# UNIT IV <br /> �G--V� &5Fitf4fl7/iJ <br /> OWNER FI E:Colt/PILETEPROPERTYOWNER/RESPONSIBLE PARTYlwooRwrloN: CHemr/a OWNER CURRENTLYMRLEWTaEHD � <br /> PROPERLY NAME N6t&L = Aj,/ .6A/v'y, ( t)� �. - Z/ 9 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME ( E-MAIL ADDRESS <br /> lLlGInJC� �Oti /(JCS/L!t Pm —ILLL fr, l4 CO <br /> Owner Home Addreu <br /> OD Z—f/4ST V <br /> QKy Ah 14 ISP BGA zip 53 v <br /> Owner Mailing Address <br /> Mailing Address City ✓lam ,^ S n I�U� State Zip <br /> RPORATKN! ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNTID PRWROO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD—LRWQCB_DTSC_EPA <br /> I'Roac� IL7G IU =NNN <br /> FACILITY FILE: COMPLETE BUSINESS/SITEI PROJECT INFORMAT/ON: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Nolt�( <br /> Is this an LISTING Project LOCATION but a NEW SCOPE OF WORK? YESA No ❑ <br /> BUSINESSIFACILITYISITE/PROJECT NAME l IDA.) Qk_'ih 14 m!-.iu <br /> SITE ADDRESS/PROJECT LOCATION r n Grc1 SUITE# BUSINESS PHONE <br /> rj'b0 EA-'5T Liu L S� �I"('�. <br /> CITY G ^ STATE zip <br /> BOARD OF SUPERVISOR DISTRICT r•l\--. �LocAAIIITION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENFfrom Facility Address Attention:or Care Of(optional) <br /> 5xt-pVnc /360L_ <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner or Responsible Party Identified above. <br /> BUsw Ess NAME �) .`� �i4YZTt} c..��Cl� „ 1��Cf)6-5 /k Attention:or Care Of top"O—, S� ( <br /> Mailing Address L—� U (� -[41W PHONE <br /> SFr 1:�AAAJJ?_ P E�_T nPICLE: 1, 75 7-r-- wq Z3y-oS) <br /> CITY To(.-4,: /O A—) CA STATE ZIP 5zo,6 <br /> ACCOHHTADORESS for fees and charges OWNER FACILITY/BUSINESSHIRD PARTY BIL <br /> BILLING AND CoN,LLU cE AL'ICVOVA.EDGNENT: I,the undersigned Applicant,certify that I am the(Arne"Dpemto"Authori:n/Agent,or Responsible Parlp and 1 acknmvledge that all PERtilr F£ES, <br /> P£reaeoEs,FN£OSCEwJv rCR1 GEs and/or AO(,RLY fHdRa£s associated with this project will be billed to meat the address identified above as the AccoDNTAUDS£sS for this site. I also certify that as <br /> information provided on this application u true and correct;and that all regulated activities will be performed in accordance with all applicable SaN JOAQULY 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 anr�rlf ility/site address,I <br /> hereby authorize the release of any and allresults,reports,and other environmental assessment information to SAT JOAQLIIN COUNTY lyIRONMENTAL DF.AI.TH DE NT as soon as it <br /> Is avagable and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) C�7 S�� ��� SIGNATURE <br /> TITLE TAx ID# <br /> Approved By I Data Accounting Once Processing Completed By Dale <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAIN PE <br /> FEE:t zr�a <br />