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San Joaquin County Environmental Health Department <br /> rE » GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> ca IUNIT IV <br /> SHADEDEND Use 911V OWNER IO# CASE III <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RES PO NSIBLEPARTYINFORMAT/ON: cHECREowNERcuRREHr4roWEAenrnEHo � <br /> PROPERTY OWNER NAME (�I H � kC <br /> Fist MI Last PHONE NUMBER <br /> E-MARAODRESS <br /> BUSINESS NAME TW <br /> � ,/JVa" <br /> CO�yn ._ _- I �nN�Ty,uG71oN. e'TN�4UNMETrll1'Le "��J' <br /> Owner Home Address <br /> STATE 2 P <br /> City <br /> Owner Melling Address I OD Lilco .E &V' <br /> state LP <br /> Meiling Address City I„T I N NVff LAA M IN 5 4 0 3 <br /> qkCORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY <br /> ::I It INV# AccouNrlD PR��OAW�.N�EoEmPIOYEE LEAD AGENCY:EHD�.RWQCS_DTSC_EPA_ <br /> S ,�rr <br /> FACILITY FILE: COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 0- <br /> YES No ❑ <br /> Is this an EXISTING ProjectLOCATION butte NEW SCOPE OF WORK? �yr, <br /> BUSINESSIFACILT'ISITEIPROJECTNAME c4ev " o flit 3SISIS �QKL — 1JN�GA'L b'i.Kl <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LCCATION �- <br /> 4107 pk%6c, hve <br /> STATE ZIP g 2--0 <br /> CITY -7 STb(XfOOT'� GA- <br /> F�`1 LOCATION CODE O I KEY1 KEY2 <br /> BOARD OF SUPERVISOR DISTRICT V ( <br /> Meiling Address NO/FFERENT7rom FeN//tyAddress <br /> Attention:orCare Of(optional) <br /> STATE ZIP <br /> Mailing Address City <br /> SIC CODE APN# '0q COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner ch-Responsible Party identified above. <br /> _ Attention:orCare OflppUon J 1 'wudwl <br /> BUSINESS NAME G / vin'Y N.�...nnW. M�hT/ 'V-( FA ��.•JJ�� rrlr <br /> N�/�'(JIT rV r'�G1����1/ PHONE _ <br /> Mailing Address I()I t�IN -��V ��15 / <br /> 1_L STATE ZIP <br /> Cm <br /> A_acaUNTAoDBMB for fees and charges <br /> OWNER FACILITYIBUSINES$ THIRD PARTY BILLING <br /> BILLING AND Coh1PUANCE ACKNOWLEDGMENT: 1,the undersigced Applicant,certify that 1 am the Olmeq Opemmry Amhonzed Agen4 or ReWmibk Party and 1 ecimowledge that all P.. 177' <br /> PENALTIES ENFORCEMENT CeARGEs author HOMY CHARLEY asse[iated with this project will be biped to me at the address ideetiged above as the ACCOUNT ADDRESS for this site. I also certify du[an <br /> information provided on this sppgeadov is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Onge" a Codes entl/or <br /> nt,or Responsible Party for the projAet <br /> hereby <br /> xuthnd STATErmaser FEDERAL Lavan rsand regulatiand <br /> s. AS the doherr environmental assessmentnformetonDewar,Operator, to SAN OAQUIN COUNTY ENVIRONMENTAL HEALTH Dted Above EPARTMEer NT as sooshe ner H <br /> hereby authonxe he release of any and a6 results,reports, <br /> is available and at the same dme it is provided to me or my representative. 5771rRG� <br /> APPLICANT NAME(PLEAeE PRINT) 11 SIGNATURE / <br /> rj I Its 41,A n1 fi <br /> TAX ID;11l� � (901 03 $ <br /> TITLE PQ'fi d"[a'i'(' 2 e�"C'r — <br /> A roved ay Dale <br /> Acoadn Oma Provaaaing Canplated By Data <br /> LAN PE <br /> SRE MRIGATION AMOUNT PAID GATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORI���� <br /> FEE:a L___-- ._ <br />