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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APR 17 2015 <br /> rF PP r. GREEN FORM <br /> PATE j, rJ , ,� MASTER FILE RECORD INFORMATION MFR ENVIROMMENWM SITENiI��f P <br /> 9uDIUAnrAs roR EHDm[Onry OIVNHi1DN mA•r0 pza85G/ CASEfl UNIT <br /> OWNER FI LEICOMPLETEPROPERTYOWNER/RESPONSIBLEPARTYINFORMATION: rtRv wnffls uon n EHD <br /> PROP[RROMERNAMF <br /> Ne) to 1LI -BNoo <br /> FFRET MI LAsr PHONENUMI[A <br /> flusmas NAME PAJ "OjlA E•MNL ODRESS <br /> lh�5P(f-wi Pro efite.5 9.+(3 L.oucaq-(.LC l"eDlT,mon dOna c��eynoldsandbraan.Co <br /> OMERHOMEADDRFSS <br /> Cm STATE ZIP <br /> O4MER M RINGADDNESS <br /> laoo Concord Avg I G+f- a,00 <br /> MuuwADDMSCM STATE 21P <br /> Concord CA Ro <br /> LT CORPOMl10N ❑MAMMAL ❑PARTuEssalP ❑GmAnhiuviAGENR ❑RESPONSRM PARR i(OTHEA <br /> BITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAOurrIDN INVR AccouNTlD PRN/10# -�AssIGH[D EMr[DYa Luop4mq EHD WO[e_DISC_EPA_ <br /> 022$ 8 lb400'F/9(oo pAo5*0e QQD 4 <br /> FACILITY FILET COMPLETE BUSINESS(SIYE/PROJECT INFORMATION: <br /> IS MIS ANEW PROJERLOCATION NOT PRENOURN'REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES I❑I/ NO rCl <br /> IS 71115IE�J'II5 AN CASTING PROTECT LOCATION,BUTA NEW SCOPE OF WORK? YES NO ❑ <br /> BUSINESS FADIID'SCT[PROJECT NAM[ fon , n <br /> SUEADDRISS PROJECTLOIATNM! SUR[ BUDN ;PHONE <br /> � C. t e, o7C�� �35.�FS--y�(� <br /> Cm <br /> STATE <br /> zn a 5 •.-LZJ <br /> BOARDWSUNKMOFDaiPICT LGcARoNCODE Nrvl NEY2 <br /> MNUNGADDRUS,IFDIFF MrAWLFAa1T•ADoRus AnegnMINICAREOF(OPIR)" <br /> Muunallooniss C'm STA.[ ZiP\ <br /> SICCWE APNN COMMURI <br /> THIRD PARTY BILLING INPOI COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIEDABOVE. <br /> Buspos;NAME ATTEmT000PCAREOr opwO <br /> MuuNa ADORES; _ PNOM <br /> c`�C� C..• �.O <br /> Cm � i SrAr[ ZIP <br /> ACCOUNTADORESS TO SEND FEESANDOARGW OWNER❑ FACILITY/BUSINESS❑ \` THIRD PARTY BILLING <br /> DILLINO AND COUPLIA\CF.ACKtOLYLEOC;IENT; 1,the undersigned Applfmnl,Cerllfy N,at I'm the Ou4rer,Opeeator,ihdllodeeddgevR,or Responsible Paro•and 111cbnmTledgD 1681 RUYERVFT/•E£g <br /> P£RILnEY,rv")RCEVfATCNAEGFS andforiloRW.TCGJRixx associated wish this project hill be billed to m0 N the Address Identified above as Ito ACCOLO'J ARORFdg for Ibis site. I nlso Certify Ilial ail <br /> InfomatimT prodded as Ibis Application Is True and corms:;And ibal all reguinted nelivill"ailf be performed LT accordance Will 1111 PppHcable S.L.v JOAQmN COUNTY ORDINANCE CODES and/or <br /> STAND,WOSand ST,LTRAnNOrrcorM LMLs AadltEctM"ONS. As the undersigned Dimer,Operator,AurOodaedAgen,or Responsible Poro•for the Pmjecl located Above Under fallp, I�/p�d_ress,l <br /> hereby Authorize 1110 release of Any And nil resuils,repog(3,and other endruummlil Assessment information to SAN JOAQUINC Hr5•"YNSTRONAIEN7A IffiLLTH DEPART ATMSOJs��y{s <br /> mWoldesame Nmei:lsis -d tomeonnympresentn ve. l•e(`eV <br /> AFvuCWTNunE(PswEPN o M1 Swnl uu � W qpR 9 F6 <br /> TRIFTmION `UV j0 <br /> l <br /> -)p,•rfu Lr H E'�'IgQN/�Nn <br /> goeaalm BY DAO Actounnxe OFRUPRoasfule CannErm RYY DATE A� <br /> SUE MRIOATION FEE! AMOUMPMo DATEOPPAYMENT PAYMEER TYPE RttuPlg CIIEIXn RECENEO BY WOq P(,LNPE <br /> e (p5U - '�'la 5'b � N•/�l/15 ✓ 37za I� �-�� :. .. <br />