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San JSaquin County Environmental Health b*artment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION, CHECK/F OWNER CURRENTLY ONFILE WITH EHD <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> city <br /> STATE 7Jp <br /> Owner Mailing Address <br /> Mailing Address City <br /> State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ <br /> OTHER❑ <br /> SITE MITIGATION—ENVIRONMENTAL ASSESSMENT._VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ <br /> FACILITY ID# INV# AccouNT ID PR#!RO ; x <br /> � �riJ EHD' FtVICB DTSC:. ERJ1 <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SITE 1NFORMAnow <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? <br /> YES ❑ No ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS <br /> SUITE# BUSINESS PHONE <br /> CITY <br /> STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE <br /> KEv7 K <br /> Mailing Address rt0/FFERENTfrom Facility Address <br /> Attention:or Care Of(optional) <br /> Mailing Address City ---' <br /> STATE zip <br /> SIC CODE APN# <br /> COMMENT; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Pro e <br /> BUSINESS NAME p rty Owner or Facility Operator identified above. <br /> Attention:or Care Of (optional) <br /> Mailing Address <br /> PHONE <br /> CITY — <br /> STATE ZP <br /> AccoL._ "?A&W for fees and charges OWNER <br /> FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND poRCE[ANTE ACKNOWLEDGMENT: T,the undersigned Applicant,certify that I am the Owner,Operator,or Au6rorized Agent of This Business,and t acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEdLENT CHARGES and/or HOURLYCNARGES associated Nvith this Operadon+yell bC billed t0 Inc at the address identified above genj oas the ACCOfr <br /> information provided on this application is true and correct;and that all regulated activities'Will be performed in accordance+rith all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> �7'ADORNss for this site. 1 also certify that all <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facillty/site address,I hereby authorize the release of <br /> any and 211 results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) <br /> SIGNATURE <br /> TITLE <br /> TAX ID# <br /> Approved By <br /> Date <br /> Accounting Office Processing Completed By <br /> SITE MITIGATION AMOUNT PAID GATE OF PAYMENT Date <br /> FEE:� PAYMENT TYPE RECEIPT d �[ CKRECEIVED BY_— <br />