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M <br /> San Joaquin County Environmental Health Department <br /> I DATE `� I L�t` " PP GREEN FORM <br /> MASTER FILE RECORD INFORMATION MFR <br /> SITE MITIGATION&LOP <br /> SHADED ARE"FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAT/ow CHEcHiF OWNER CuRrreNrcroNFicewirH EHD E] <br /> PROPERTY OWNER NAME �i M I —( "C-- ( 11z) -7g.3^ IS <br /> 1 <br /> First MI ./ Last PHONENUMSER <br /> BUSINESS NAME \—k <br /> 1 EMAILAODRESS <br /> Owner Home Address <br /> city STATE ZIP <br /> Owner Melling Address <br /> gK51 Ai-Ktr`so., s+, S,, .,re too <br /> Mailing Address City State ZI <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL AssESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# ACCOUNTID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated BUsinB s? YES ❑ NO <br /> BUSINEsWFACIUTY/SITENAME <br /> SITEADDREsB ( �'t"�• ` SUITE# BUSINESS PHONE <br /> -i\- <br /> CITY cA TATE ZIP <br /> BOARD OF SUPER VISOR DISTRICT LOCATION CODE Kav1 KEY2 <br /> Meiling Address KD/FFER ,rfrom FeellifyAdd�a� Attention:orCare Of(optional) <br /> ✓✓AAFF <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optiona/f <br /> RcADrS u,S., enc, f}cca,nt Pa ah/e <br /> Halling Address PHONE <br /> 4; <br /> 6 3/0 P(47-a ./ 'pr S w:4e. 00 <br /> CITY / QnA cin ch Q r� <br /> I STATE�O ZIP CJo�pL <br /> ACGOVAEA2agm for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PER,uir FFFs, <br /> PENALTIES,FNFORCFAIE'NTCHdRGF.s andher HOURLr CHARGES associated With this operation will be billed to me at the address Identified above as the ACCO(INTADDRESS IDr this site. I also certify that <br /> nil Information provided on this application Is true and correct;and that all 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,or agent of the property located at the above facility/site address,1 hereby authorue the relense of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEpRTMENT as loon as it is nvailnblc and at the same Time it is <br /> proAded to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNA <br /> TITLE TAX ID# <br /> Approved By Dab Accounting Office Processing Completed By Defe <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CMEOK# RCCEIveG SY WORK PLAN PE <br /> FEE:$ <br />