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San Joaquin Gounty tnvlronmental Healtn Liepanment <br /> DATE N TER FILE RECORD INFORMATION OFR'r GREENFORM <br /> SITE MITIGATION & LOP <br /> BHRUm <br /> AREAS,FOR ENO use o11LY OwNER ID# b k cAaE* UNIT IV <br /> Wtzi <br /> 11 <br /> k LA <br /> OWNER FILE:COMPLE7E THEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON. CREcNIF OWNER CHRRENTLYONFae WITH EHD <br /> PROPERTYOWNERNAME r e< <br /> Find Mf Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> C /P,PSr�PnC �, <br /> Owner Home Address <br /> city GL p� /D// CL STF Lis <br /> 1 5 3 0 <br /> Owner Mailing Address <br /> SA N4 4— <br /> Mailing <br /> Melling Address City Stafa Zip <br /> i <br /> CORPORATION❑ INDWIOUA1.0 PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY UP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDN INV* ACCOUNTIO -PRN RON ASSIGNED EMPLOY EE LEADAGENCY:EHD�RWQCB_OTSC_EPA <br /> Oo 0 la 916b 3bZ Zoo$ b Z 19 <br /> FACILITYFILE COMPLETE THE FOLLOWINGBUSINESS I FACILITY I SITE INFORMATION.- <br /> Is <br /> NFORMATION:Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ A-14 <br /> Is this an EZISTtNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ Niel <br /> BI15 W ESSIFACILITY/SITE NAME f�/ <br /> 02o4rUe/ie le-) <br /> SITE ADDRESS SURE* BUSINESS PHONE <br /> CITY V STAIr ZIP S <br /> Lsc�� �G-7,z C <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address NDIFFERENTrtom FacNNyAddi esa C1 Attention:orCare//Of lopNona/J n 1 <br /> 2 GY' ( c� rnGt rf Al / I bL oL La <br /> Mailing Address City STATE LP <br /> � 3cic /ave CA- "/ •S3 � C_, <br /> BIC CODE APNN ZZ�OI I `(� COMMENT: <br /> THIRD PARTY BILLING INFO: Compete if Billing Party is different from Property Owner or Facility Operator identifiedatwve. <br /> BUSINESS NAME q�wAttention:orcare Of (opLfasdl TcL w bqJ l S ` <br /> aw— IS q <br /> Mailing Address I3Go PHONE3932-- <br /> CITY STATE <br /> �ClJc.O� 044 yS3Zt, <br /> AccouHTADOdE56 for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the Undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent Of lids BeninesS, owled et ERa1/T F£ES, <br /> PENALTIES,ENFORC£MEWCHARGFS and/Or 11OURLYCHARGes associated With this Operation Will be billed t0 me at the address Identified above ae the ACCDUNTADDRFra'for Ihh Site. I Aso certify(hat all <br /> information provided on this application is true and correct; and that all regulated wdvi&s Will be performed in accordance With all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE andlor FEDERAL Laos and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I torcby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH DEPARTME soon as it is available and a(the same(ime it is <br /> provided to me or my representative. <br /> Y-APPLICANT NAME(PLEASE PRIM; �J J�KtLJ�jl'V7 SIGNATURES, <br /> TITLE TAxI <br /> l�¢o <br /> Approved By Date Acco..Unit Once Processus,Completed By Date 1 <br /> SITE MITIGATION AMOUNTPato DATE OF PAYMENT PAYMENT TYPE RECEIPT* Al <br /> ECKI N9, RECEIVED BY WORK PLAN PE <br /> FEE:S6(QIOO .�(,I19roo It� I II � 'Cl�� /W a153 <br />