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San ,foaquln county tnvlronmental Health Department <br /> DATE 3 _ a g_ (/ OSTER FILE RECORD INFORMATIO&FRaa GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHADED ARE AS FOR END UaE ONLY OWNER ID#Q b CASE# UNIT 'V <br /> OWNER FILE-.COMPLETE7NEADLLOW/NOPROPERTY OWNER/NFORMAno CNECKIFOWNER CURRENrLYONFaewirNEHD � <br /> PROPEmv OWNER NAME `„ <br /> Fkw MI vLast PHONE NUMBER <br /> BUSINEss NAME GMAIL ADDRESS <br /> R,Psic�pne �, <br /> Owlasr Home Addlasa <br /> 00 �c7�rnq'�� S�f <br /> City 1 /O $TAT LP� �G <br /> Owner Mailing Address <br /> SQ wt-k- <br /> Mailing <br /> Mailing Address City Syy Zip <br /> _.—LCORPORATION❑ fND1VIOUALO PARTNERSHIP[I FED AGENCY ElOTHER❑ <br /> II. <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY LE LIP t WATER QUALT'_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INv# ACCOUNTID +SRN/R0# A991GNED EMPLOYEE LEADACENcY:EHD�.RWQCS_DTSC_EPA_ <br /> Oa a 5 Li D N 9kb 3 36Z zoos 6 i. <br /> FACILITY FILE COMPLETE TNEFOLLOW/NG BUSINESS/FACILITY I SITE INFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ /Vla <br /> Is this an ExISTfNG Business LOCATION but a NEw TYPE of regulated Business? YES ❑ No ❑ JI//,4 <br /> BUSINESSIFACILITY/SITE NAME <br /> SITEAODRESS ^ I SURE# BUSINESS PHONE <br /> CITY STATF ZIP <br /> LA L� 5� � �= <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYi KEY2 <br /> Mailing Add reaa/fD/FFERENTtrain Fac//lfyAddreas Attention:O Cana Of(optlona/J <br /> --?- oc IZE-d /"elp r f 15, r', a <br /> Mailing Addreaa City E STATE ZIP <br /> sc'� /oma <br /> SIC CODE APN# Lz�06) �� DaMNENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator idenGBedabove. <br /> BUSINE99 NAME Attention:orCare Of (srptYom/J T� <br /> w'cz�— D110 3 <br /> Mailing Address PHON <br /> Gm STATE <br /> ,'rSGv4Z('J U'4 ?S37 o <br /> AcceuNrADDREss for fees and charges OWNER FACILrrY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of thio Bminess, owled e I £RANT F££S, <br /> P£NALvast,ENFORC£MENTCNARGEs andler RODRLTCNARGES arsociated with this operation will be billed to me at the address Identified above as the ACCOyorrADDaEsS for this she. I also certify that all <br /> Information provided on this application U true and correct; and that all regulated activities will be performed in accordance with all applicable SAN AOAQUtN COUNTY Ordinance Code and/or <br /> Standards and STATE and/or FEDERAL Lam and Rcguladom. As the undersigned mvner,operator,or agent of the property located at the above facility/site address,I hereby authorlac the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME ' soon as it is available and at the some Onto it is <br /> provided to me or my representative. <br /> (APPLICANT NAME(PLEASE PRINT, b ffrL) SIGNATURE. <br /> TITLE <br /> Approved By Date Accounting Once Pfocesaing Completed By A �j Data ,^1 I. 1 <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE CHECK# RECEIVED BY WORK PLAN PE <br /> ( <br /> FEE:$610,00 " 00,00 I'I'I ? II I/ RECEIPT# 1' 6� 0 a1s3 <br />