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San Joznuin County Environmental Health Dapartment <br /> DATE 2 /2�It MA•ER FILE RECORD INFORMATION"Azo GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAa FOR END USE ONLY OWNER IDN CASE# "EGEIVED <br /> UNIT IV <br /> OWNERFILE:COMPLErEnlEFOLLOw1NcPROPERTYOWNER/NfoRManoN: �:Ctizoxls, <br /> PROPERTY OWNER NAME I p K <br /> First MI Last PHONENUMDER <br /> BUSINFS9 NAME EiAA1LADORE99 <br /> f ENVIRONMENTAL HEALTH <br /> Owner Home Address <br /> Po o � O <br /> city STATE zip <br /> o Cv°, q 2--2 c> <br /> Owner Mailing Address 10 <br /> Meiling Addre as City Q State zip 'j�S, <br /> CBRPORATION 01� lumv uAt.El PARTNERSHIP 11 PED AGENCY EI OTHER El <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITYID# INV# ACCOUNTIO PR#IRON ASSIGNED EMPLOYEE LEADAGENCY:EHD RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS FACILITY SITE/NFORmwio .' <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,0 No ❑ <br /> BUSINEssfFACILITYISITE NAME / _ dI <br /> ✓C7(�jt r <br /> SITE ADDRESSOF �w ^ SURE# BUSINESSPHONE <br /> L / /V T(1 G/ STATE ZJP <br /> CITY C-1,)— �j'_7 t 2 J <br /> SOARDOFSUPERVISORDISTRICT LOCATION CODE KEYS KEY2 <br /> Meiling Address HDIFFERENrIrornFac//Hy Address Attention:orcare Of(op#ona9 <br /> Mailing Address City STATE zip <br /> SIC COOE APNN COMMENT: <br /> THIRD PARTY BILLING INPO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME ,O ' u Attention:orCare Of(OPOOnW) <br /> Mailing AddsPHONE <br /> ea. STATE <br /> clTv �ct�..�r� C/� LCIS 2 <br /> AGffitiyrA mss for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPL4INCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENToncE ENTCMARGEs and/or HOURLYCHARGES associated with this operation win be billed tome at the address identified above as the Acxxuw rAnDxEss for this site. 1 also certify that <br /> all information provided on this application is but,and correct,and that all regulated activities will be performed in accordance with all applicable SAN IOAQIIW COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly 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 as soon as it is available and at the same time it is <br /> provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT)��( � y� (_(' Q_ SIGNATURE Ii1/d4a,.-. kt <br /> TITLE !— TAX ID#0_0Z,/_ „ <br /> ` I gill <br /> Approved By flab AceasnRnB OMea Proceeeing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKN RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />