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ifJsf'ix-'.• •__ .r_. '1�.frJ.L:.tll"s..v.�rs:JiFiia:Yw:.7 i R'-fiL-�'r.r'L:.�Ylrt.. -. .•....-s a..--::::::-. <br /> . v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE / MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOII EHD UBE ONLY OWNER IDS CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER 15CURRENnrONFILE wITN EHD ❑ <br /> P ROPERTY OWNER NAME City of Lodi (209)333-6800 <br /> FIRST Ml LAST PHONE NUMBER <br /> E-MALI_ADDRESS <br /> BUSINESS NAW <br /> OWNER HOME ADDRESS <br /> CITY STATE —7J� <br /> Lodi CA 95240 <br /> OWNER MAILING ADDRESS <br /> 221 W. Pine St. <br /> MAILING ADDRESS CITY Lodi STATE CA zP 95 240 <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ®GOVERNMENT AGENCY NJ RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INv# ACCOUNT ID PR#IRO# ASSIG ED EMPLOYEE LEAD AGENCY:EHD RWQCB�DTSC_EPot�lA <br /> f I�qq 9,6b <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <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 /> BUSINESSIFACILITYISITEIPROJECTNAME Former Busy Bee Cleaners <br /> SITE ADDRESS I 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 SUPERV18OR DISTRICT LOCATION CODE KEYi KEY2 <br /> I <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:OR CARE OF(OP770NAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> city right-of-way <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:OR CARE OF (OP770N4L) <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 COMPLIANCE ACKNOWLEDGNIENr: 1,the undersigned Applicant,certify that I am the Owner,Operator,Aadlorized Agmt,or Responsible Park,and I acknowledge that all PERADTFEES, <br /> Rc;,auiEs,L'NFORCE.ILENrCFL-RGES and/or HouRLI'0L4RGEs associated with this project will be billed to me at the address identified above as the AmouVTADDRESS for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all appBcable SAN JOAQULN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Audlorized Agent,or Responsible Pnrq!for the project loca above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH SPAR' 'NT as soon as it is available <br /> and at the same time it is provided W me or my represenL•I've. <br /> APPLICANT NAME(PLEASE PRINT) ( L f SIGNATURE <br /> TITLE cl <br /> TAX ID# <br /> APPROVED BY DATE 11 <br /> ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> NA- <br /> SITE MITIGATION AMOUNT PAID rATE PAYMENT =PAYM-ENTTRECEIPT# CHECK# REGEIYED BV WORK PLAN PE <br /> FEE. A 4_ – <br />