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San Joaquin County Environmental Health Department <br /> DATE s MASTER 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 THE//FOLLOW/NG PROPERTY OWNER/NFORMAT/ON.' CHECKIF OWNER CURRENTLYONF/LEW/TN EHD <br /> PROPERTY OWNER NAME O� O I / <br /> 1 111JJJFirst MI Last \PHONENUMBER <br /> BUSINESS NAME &MAIL ADDRE""M/1 Y <br /> Owner Horne Address <br /> ETIVIRO - EN7;6„ <br /> city STATE L-ri 7 ERVICE;' <br /> Owner Mailing Address <br /> Mailing Address City / fthe Z P —Zip <br /> S/VvK{a�, C/� -q Solo <br /> ❑ <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIRONMt�►TAL AtisesaMCNT_VOLUNTARY CLEANUP_WATER QUALITY_KW PIPELINE INVEsmGAn0N LOP <br /> FACILITY <br /> ID* INV* ACCOUNT ID PL32— Gi � <br /> A*111 # AssIGNED EMPLOY ENCY:EHD RWQCB DTSC EPA <br /> 23?? ` IZZ L3Dq EE LEAD AG <br /> 11 <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No E- <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESs/FACILrTY/SITE NAME A �J C' ��` �'`(•/(_ <br /> SrTEADDRESS �1 J J- ` SUITE# BUSINESS PHONE <br /> NG.V r7 Lam_ <br /> CRY c' STATE ZIP <br /> aS�Uh <br /> BOARD OF SUPERVISOR DISTRICT 6 LOCATION CODE © ( KEY1 KEY2 <br /> Mailing Address KD/FFERENTMOM Fac!/Hy Address Attention:orCare Of(opfiorta/f <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 ��QQ r Attention:W re Of(4 �ORa/J <br /> SOGCu 1e-y <br /> Mailing Address-3DIS Cr,N SZ?PHONE` l L(I I x <br /> Cin n f—( STATE <br /> ,C ZIP L(D r-7L- 0.n L O l� Ct -7-Z D <br /> ACGgUATADRBEW for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACANoy,LEDGNiENT: 1,the undersigned.Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEALEAT CHARGES and/or HOURLY CHARGES associated with this operation wi0 be billed to me at the address identified above as the Arcot ATADDRESS 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,l 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) <br /> �rtS cJu(2t^� SIGNATURE <br /> TITLE // TAX ID# <br /> Approved By Oete Accounting Office Processing Completed By V' Date 5 f L <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENTPAYMEN�TTYPE RECEIPT# CHECIt# RECEIVED BY WORK PLAN PE <br /> FEE:$ ,� b � li/✓Q` �- <br />