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u <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION`SMI=R" GREEN FORM I] <br /> SITE MITIGATION <br /> p&SLOP <br /> ENAaw AREAS Pan END usE oRLY OWNER ID# CASE# U IC]O 6 B tl <br /> OWNER FILE:COMPLETE PROPERTY OwNERI RESPON818LE PARTY INFORVATION: t�cx,POwkALnelsCr>�YxrouY�tarnf EHD <br /> PROPERTY OrXER NAM C , - 6. (";'-(�D '1 7r r , <br /> FiRsr M, LAST PHONE 11b6:=ER <br /> SUMNEW NAME _ E-vAn.AoDrAft <br /> OWNER IAnoaoaa <br /> Cm STATE ZIP <br /> c/4 f /C <br /> OWNER MAOLM ADDREW7 <br /> f7AWNOACITY STATE ZIP <br /> ❑C MIMATION ❑Ixo&IMOL ❑PAirru ❑GWAM=ffAGMW ZR.WONOt=PARTY ❑arwit <br /> SITE G'Ii maATION_ENVIRONG7ENTAL A88E$=ErIT_Vol.UriTARY CLEANUP_WATER QUALITY,HW PIPELINE UIVEwnGATION_LOQ'_ <br /> FACILITY ID# INVO AccouHT 10 PR fid RO# AeelitNEo EC.PLOYEE I Le"AQWXY:EHD_RWfQCB X DTSC_EPA_ <br /> Ro S-i L( <br /> FACILITY FILE:COC^PLETE BUSINESS I SITE/PROJECT INFORMTION: <br /> IS THIS A NEW PROJECT LOCATION No PREVIOUSLY REGULATED BY THE ENVIRONt.7ENTAL HEALTH DEPARmENT? YES ❑ No �] <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> Bwmc=FAcamfBITEIPRoj=Nn <br /> SITE ADOR=I PROJECT LOCATION , Surm# BtIaw-w PHom - <br /> CITY STATE ZIP <br /> SoARD of SuPeRmw Dt3mwT d LOCATpN Com 6 1 KEYt MY2 <br /> L ATL=ADDm=,tFDwFaRENT i AooRELO I A'TTEursom QQCARE OF(OTnamL) <br /> MAI.SKi ADORM33 Cn Y STATE Zip <br /> SIC Cow APN# COC^18IT: <br /> THIRD PARTY BILLING INFO:COUPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUS=86 NAS ATTENTION:ORCARE OF(OPMMU.f <br /> LUxr tlAOORM PHONE <br /> CITY STATE ZIP <br /> AtxOtRITAOD6tEm>IToemFEEBANDCNARGEs: OWNER FACILITY/BUSINESS❑ THIRD PARTYBILIING❑ <br /> BTLuNG AND CO:NPLTA?iCE Ajallom.EDGMIF\7: 1,the undersigned Applicant,certify that I am the Owaer,Operator,AntAofizedAgent Or Responsible Parry and I acknowledge that all PERAOTFEES, <br /> PENALTT ENFORCEMENT CAURGES and/or HODRLYCBA M associated with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site.I also certify that an <br /> information provided an this application Is true and correct;and that all regulated activities wig be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL,Laws and REGULATIONS.As the UadersigDed Owner,0^-mw,Auaw-ked Agent or Respo Parry for the project located above under facillyhhe address,I <br /> hereby authorize the release of any and all radia,reports,And other environmental assessment information to SAN, <br /> QUDs CoR_oxmENTAL Ike DEP 1FN as S906 as it is available <br /> and at the same time I is prm'Ided to roe or my representative. /l�(`f/'//(/ . <br /> APPt KWH HAMS(Pt t3AW PRINT) I <br /> Get!`.�. P„� �,/•�= ( sIiNATu Xn�} / c `�,{� <br /> TITLE O! /�Jrd�p�i^'St✓ ! ^TAX IDD�� UV ��CJ/✓ C/V �� <br /> AFIYAVW CY DATE AcoouNTm OFWDE PRoce==Co`.:P18TED BY DATE <br /> SITE wT Aco PAID DATE oFPAmsuY PAYC:HT TYPE RECEm# CHEOK C RECEIVED BY QC"t PINI PE <br /> FEE:$ J <br />