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San J av quin County Environmental Health briiartment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 11 5-- %3 - I I <br /> "°G '4 / SITE MITIGATION& LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# <br /> S�too4 7/G C�D <br /> _ UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWING PROPERTY OWNER/NFORAWION: CHECKIF OWNER CURRENTLYONFILEwim EHD <br /> PROPERTY OWNER NAME D&, v � 4 qZ r Z& <br /> First MI Last PHONE NUMBER <br /> BUSINESSNAMEIDQE-MAILADDRE S <br /> V S Qthim /I <br /> Owner Horne AddressG Iz(0 Cl '� ` <br /> -E' a a <br /> city STATE ZIP <br /> IF V'Lhc� C A q,5-23l <br /> Owner Mailing Address <br /> Mailing Address City \ ` t State -,\ Zip 1 1 <br /> CORPORATION❑ INDIVIDUA15;� PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SIT!MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# AccoUNT IO PR#/RO# ASSIGNED EMPLOYEE LEAo AGENcY:EHD_RWQCB->(.OTSC_EPA_ <br /> 3 .30 atv y <br /> FACILITY FILE COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION. <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 Business? YES ❑ No <br /> BUSINESS/FAcILITYISITE NAME "5 <br /> SITE <br /> LL ` <br /> $ITE ADDRESS 7 SUITE# BUSINESS PHONE <br /> CITY STATE AIP <br /> BOARD OF SUPERVISOR DISTRICT I LOCATION CODE / KEY1 KEY2 <br /> Mailing Address ffOIFFEREA?from Fac( Ad rasa Attention:orCare Of(opHona/f <br /> (, V, I CA '0^- <br /> Mailing <br /> aMailing Address City STATE IP <br /> SIC CODE <br /> 1[tkPN# COMMENT: <br /> Iy5 -oG3-off <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identi>ied above. <br /> BUSINESS NAME Attention:orCare Of(opdona/f <br /> Mailing Address PHONE <br /> CITY STATE zip <br /> AcowATADDHEss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Apl icant,cer' that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEAIENTCHARGES and/or HDURLYCHAROES associated wNr4frillperation Will be billed to meat the address identified above as theACCOUN'I'ADDRESS for this site. I also certify that <br /> all 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALT11 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to or my representative. T� <br /> APPLICANN T NAME(PLEASE PRINT) Q� � I, � SIGNATURE C�� <br /> TITLE u z <br /> =,L TAX ID Z3R 1 J3— <br /> G� 7 <br /> Approved By Date Accounting office Processing Completed ByCOL I <br /> Date !tP <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED By ORK PLAN PE <br /> FEE:7 `�� <br />