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'wan Joaquin County Environmental Iealthlrepartment <br /> DATEiE==[-.MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADED AARKAS FOR EHD USE ONLY OWNER IOC CASE N UNIT IV <br /> OMMERFILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION' CHECK IF OWNER CURRENTLYON FILE WITH EHD <br /> I <br /> PROPERTY OWNER NAME <br /> J — <br /> First M) Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> City $TATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_ HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# AccouNT ID PR#/RO N x�.y x+ § # r., �� I ,�• <br /> f k li �jP o E tYA Cr EHO R( t"B y ny'sc <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY I 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/FACILITY/SrTE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERvmoR DISTRICT LOCATION CODE KEY1 KEYZ <br /> Mailing Address if DIFFERENT from FacilityAddtess Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> 5!C CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or-Care Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE 71P <br /> ACccUMAOOREss 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 I acknowledge that all PERAnT FEES, <br /> PENALTIES,ENFORCEAfENT CA4RGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for tbl3 site. I also certify that all <br /> information provided on this applicatiou is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNry 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 ns soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAX ID# <br /> Approved By Data Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENTPAYMF_NTTYPE RECEIPT"b CHECK# I RECEIVED BY -_WORK PuiN'PE <br />