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SAN .J(, ,,LIIN COUNTY ENVIRONMENTAL HEALTH U— .RTMENT <br /> DATEMASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CNECK1Fl7wNER/5CURRENTtrONF7LEwir"EHD <br /> PROPERTY OWNER NAME Cityof Lodi (209).3-3.3-6800 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS <br /> CIT/ STATE ZIP <br /> Lodi CA 95240 <br /> OWNER MAILING ADDRESS <br /> 221 W. Pine St. <br /> MAILING ADDRESS CITY STATE ZIP <br /> Lodi CA 95 240 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ®GOVERNMENT AGENCY ®RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# AcCOUNT ID PR#/RO# ASSIGED EMPLOYEE LEAD AGENCY:EHD�_RWQCB DTSC_EPA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW 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 /> BUSINESSIFACILITYISITE/PROJECT NAME <br /> Former Busy Bee Cleaners <br /> SITE ADDRESS/PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 40 N. Main St. (cross streets: E.Oak St. and E. Pine St.) <br /> CITY STATE ZIP <br /> Lodi CA 95240 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY'I KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> city right-of-way <br /> 77 <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 /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER® FACILITY/BUSINESS❑ THIRD PARTY BILLING[] <br /> BILLING AND COMIIJANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Oamer•,Operator,authorizer/:igemt,or Responsible Parts,and I acknowledge that all 1 ERAfITfFf,,5, <br /> 11.Ys:4L 77E.S,),,VFORCF,%IFATC.�IL4RGFS and/or H07RLTC.H4RGE.S associated with this project will be billed to me at the address identified above as the:ICCOII,NTADDRE&S for this site. 1 also certih•that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE.and/or FEDER la,Laws and REGULATIONS. As the Undersigned OaK'ner,Operator,Authori.7ed agent,or Responsible Para for the project loca above under facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQL IN COUNTY ENVIRONNUNTAL HEALTH SPAR NO-'N I as soon as it is available <br /> and at We same time it is provided W me or my represents �— <br /> APPLICANT NAME(PLEASE PRIHT� ( 1 SIGNATURE <br /> TITLE CTAX ID# <br /> t J <br /> LSAPP-- <br /> DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> EE:s <br />