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San .. .dquin County Environmental Health .)artment <br /> DATE11 �[� u MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER 109 CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTYOWNER/NFORMAT/ON.' CHEcKIF OWNER CuRRENnroNFicewiTH EHD E] <br /> PROPERTY OWNER NAME T�,e A r) ( 1 <br /> First Ml Last \PHONE/NUMBER <br /> BUSINESS NAME (' / E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address O D X 0 0 3 9 <br /> Mailing Address City /"I y I�N ;v Ste _ zip <br /> G✓I <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP;, FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR ill/81111111111IG <br /> ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB DTSC_EPA_ <br /> DD 3 \\off °1 �� `j <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMATlom <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 ❑ No <br /> BUSINEs81FACILITY1$nE NAME C1n ' l l,oo�0 !n!J / [.0 <br /> C/o � ll� L�'_TT1J-O <br /> SITE ADDRESS �J O , I ,^ SUITE# BUSINESS <br /> a vy jot) c 9/6 7 � <br /> Cm �--,� $?TA ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom FacilliyAddress Attention:orCere Of(option/) <br /> Mailing Address City STATE ZIP <br /> SIC CODE = APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME it ^r'( /1 S,`O�,f4 /.5, Attention:orCere Of(opiYonl) <br /> l'1 /'"1 7 '7T r�, <br /> Mailing Address <br /> l�/ � Lo wt P4/bN .4 vc H ✓�� 5�.;4 -')d� PHONE2 a 9—S 7 <br /> CITY/-I <br /> d d C S 4 STATE('14 ZIP r <br /> A=yN.rAvoRess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AcKNow'LEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERAfIT FEES, <br /> PL'NALTtEs,ENt'oRCEMENTCILARGES and/or HOURLrCHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) �Q d H C y/7/ 'r`�,n SIGNATURE �p-/—/— <br /> TITLE G TAX ID# N A <br /> Approved By T Deft AccourMinq Office Processing Can leted By Nt-- Dab 2 L <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />