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----]Sar*aquin County Environmental Health�3partment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAE FOR END Ua�Qx6y OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY/NFoRMATioN. CHECRIF OWNER CURRENTLYONFILEWITH EHD O 11 <br /> First MI J2S� PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City ' Sta <br /> FXCORPORATIONte Zip1i�� ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_—VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# =AcCOUNTID PR#/RO#� ASSIGNED EMPLOYEE LE AD AGENOY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMAT/oN: <br /> IS this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ® No ❑ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILITYISITE/PROJECT NAME `*1 <br /> ,v CA <br /> SITE ADDRESS/PROJECT LOCATION SUITE# BUSINESS PHONE <br /> - <br /> CITY <br /> STATE ZIP <br /> I <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE � qpN# � COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> ACCOI&T-AODRESs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> III Lt.6C A,D COMPLIANcE A(wwwi.FDGAIF\T: [,the undersigned Applicant,certify that 1 am the Owner,Operator,Authurized.1genf,or Respurnible Party and 1 acknowledge that all PER.tfil FEE.1, <br /> Pes:u.nEs',Em-ow I..'.s1ENT'CHAR6ES and/or 110URLYC761R6ES associated with this project will he billed to meat the address identified above as the AC(lu ATADDREAS for this site. I also certify that all <br /> Information provided on this application Is true and correct;and that all regulated activities sill be performed in accordance ssith all applicable - OAQUIV('O1:1T1'Ordinance(hod es And/or <br /> Standards and SLATE and/or FEDEI At.Laws and Regulations. As the undersigned ON'ner,Operator,Authorized Agent,or Responsible Parte for c o.located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SA V dOAQI'IN COIX"I'Y EN ( .Il:\"h:U.HE: t:P:%RTNI ENT as soon as it <br /> is available and at the same time it is provided to me or nn'representative. <br /> APPLICANT NAME(PLEASE PRINT) -fyP�N �, D r. SIGNATURE <br /> TITLE t l TAX # <br /> Approved By Date Accounting Office Processing Completed By tBYJtWORK <br /> SITE MITIGATION AMOUNT PAID I DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# [RECEIVED PLAN PFEE: 4� <br />