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San •ruin County Environmental Health,%.Opartment <br /> DATE 13MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 1 -5 SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDS CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION: CHECK/F OWNER CuRREHTLYOHF/LE'W/TH EHO <br /> PROPERTY OWNER NAME Y� �— \ * '{V/Z— 1?& 2— <br /> First MI Last PHONE NUMBER <br /> BUStNEss NAMEID E-MAIL ADD <br /> S <br /> 2v.3 � QC 0.. <br /> Owner Home Address (D'Z(O 4 L T 'iN, 4 0.p <br /> city STATE ZIP <br /> r L-'r- , C# 1 <br /> Owner Mailing Address <br /> 0.1/M t_ 9--) <br /> a1�o J <br /> Mailing Address City \ • ` r State ZIP t 1 <br /> CORPORATION❑ INDIVIDUA15p PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> $ITE MITIGATION_ENVIRONMENTAL AsswmacT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVEETIOATION_LOP <br /> FACILITY IDS INV# ACCOUNTID PR#/RO# L <br /> SIGNEDEMPLOYEELEA0AGENCY:EHD_RWQCB—! DTSC_EPA_ <br /> FACILITYFILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' <br /> Is this a NEW Business LocATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No <br /> 5 <br /> BUSINE33IFACILITY/$ITE NAME rJ �� ` <br /> G 7 � <br /> SITE ADDRESS ^ 1 SUITES BUSINESS PHONE <br /> CITY STATE zip <br /> C-It /s <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE J KEY1 KEY2 <br /> Mailing Address IfD/FFERENTfiomFao Adglress Attention:orCare Of(optional) <br /> Halling Address City /V_ n �t _l- STATE P <br /> C 1l� \lel` rA <br /> SIC CODE -06 <br /> G 3- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaciiity Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(optional) <br /> Mailing Address PHONE <br /> CITY STATE zip <br /> AGGOVATAppRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE.ACKNOWLEDGMENT: 1,the undersigned Ap icant,cer <br /> A that 1 am the(honer,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENAL17ES,ENFORCEMENTCHARGE.S and/or HOURLY CHARGES associated vi operation will be billed to me at the address identified above as the ACCOUN'I'AUbRESS 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,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> provided to me or my representative. ` p ^ C <br /> APPLICANT NAME(PLEASE PRINT) Q e )= (� SIGNATURE c�(]_ <br /> TITLE TAX \�»)�T�"�� <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MIT IGATI N AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:Y ') 7 <br />