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SAN.IOIN COUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> DATE �.1 t.�_I�j MASTER FILE RECORD INFORMATION EEMFRly GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR END USE ONLY OWNERID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE <br /> /PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER is CURREwn Y ON FILE WITH EHDEI <br /> PROPERTY OWNER NAME GR� SILVEKS ( ) <br /> FlRsr M, LAST PHONE NUMBER <br /> BUSINESS NAME E-MAILADDRESS <br /> OWNER HOME ADDRESS <br /> COY STATE LP <br /> OWNER MAILING ADDRESS NE -zND�'PEf`�D�N�T 0 -r� 11q <br /> MAILING ADDRESS CITY \ fq v � STATE F 1 ZP 21zo <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY . ❑OTNEp <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> AGENCY:EHD-"K-RWQCB_OTSC_EPA_ <br /> Jo I4NN y <br /> FACILITY ID# INv# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE TEAD <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> ISTHIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No � <br /> BUSINESSIFAOIIRY/SITEIPRWEdf..NAME rolge^ © 1 ' D` , I <br /> SITE ADDRESS I PROJECT LOCATION JJ1�ll 1/ --b <br /> 74 — W ST SURE# BUSINESS PHONE <br /> CITY �'�f ,is ((� .-1llh— CA STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT S LOCATION CODE 3 KEY'/ KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORGANS OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> —11 <br /> SICCOOE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME fJ 1, (��+r r n 1/' I A) T.�1 n\I A EfJTION:ORCARE OF OPOONAL) <br /> MAILINGADDRESS 14O 4 F� pgj�yv�1 V IU I�IV GC. 1�1(T� �o PHONE S-1 <br /> ,\u wy 18 <br /> ACITY O STATE IP <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLIN <br /> BILLING AND COMPLIANCE ACKNOWISnGNEN'f: 1,Her undersigned Appbicanb certify/hat 1 am the Oa,ner,Operator,AutborkeridgWR,or Responsible Parry,and 1 aClurnwledge that all PEMIRTpEF.19 <br /> PENILTiFe,CNF'ORCENEATG/ARGLS nn(Uor/IOfm ),01ARG£s associate,[with this project will be billed to meat the nddress identified above as the ACTe wAnnr vcc for this Site. 1 also certify that nII <br /> infurnation pmvided on Ill.application IS trot and r.r'r'ect:and that nil rxgulated netiviHes wRl he padm'nred in neconlanee with all applicable SAN JOAQINN COUNT'01DIWINCE CODES 1110!.1- <br /> S'R\NDARDsan(]STATE.lllla'I''F,DF.NALLar5.11ditF.GUI.ATIONS. Asthe.ndemignedONller,Opemmr,AuilrorizedAgenbor Responsible P for the projSA located abnvcunderfacility/Sitenddress,I <br /> hereby i.tlrmiZe Ilre releme,of any.rul.bl res.115,reports,n..I het'eadrnm.e.lal Bsrannenl ild.rmatial 1.SAN JOAQUIN COUNTY C' NME AL F. TII DBI'.GfTN1ENT a5 Sanin 115 if IS:Ivail0I11C <br /> and at the same time it is proeided to one y represent:Gire. X19 <br /> APPUGANFNAME(PLFaeE PRINT) �` -� (>� SIGNATURE <br /> TITLE TAX ID# <br /> APPROVED BY DATE ACCOUMINOOMCEPROCESSINOCOMPLE VORY DATE <br /> SITENNUGATION AMOUNT PAID DATE SOF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECWORK PLAN PE <br /> FEE:S 7S 37s 21-I� e(fc-Er NoG EIVE08Y �29So <br />