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San Jc;aquin County Environmental Health DOartment <br /> sr P>' GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION & LOP <br /> SHADED FOR END USE ONV OWNER IDN CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY/NFORMAT/ON: CHE(C1A_1vOWNERCuRHENTLymFaEwLrHEHD � <br /> PROPERTY OWNER NAME (W7) -7b <br /> Fist MI Last PHONE NUMBER <br /> �ILAODRESS <br /> BUSINESS NAME C0"L <br /> VTC CDn15TCAACT1uN. b"MI14UNMEMN'LE •GdN <br /> Owner Home Address <br /> STATE ZIP <br /> City <br /> Owner Meiling Addreu <br /> I OD NttO Pvt, PN - j•11-F _ <br /> Mailing Address City S I"t Zlp Ic-cu 0 3 <br /> IA I N NV"01A <br /> I�CORPOMTI[W ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDN IxvN AccouNr if PR NI RO# ABSIONED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA <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 <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESSIFACILT'ISIEEIPROJECT NAME CNS")-, Sl(b 351 SIS 1�P KI�� V Npf�L �Y'- b`'i,p l <br /> Sumill BUSINESSPHONE <br /> SME ADDRESS I PROJECT LOCATION —� <br /> #'107WA,YI G v— <br /> STALE ZIP <br /> Cm Gq_ R$'Yd—] <br /> 51•D(X-TDTJ <br /> BOARDOFSUPERVISORDISTRICT LOCATION CODE KLY1 KEY2 <br /> Meiling Address NDIFFERENT1rorn Fec#1fy Address Attention:orCere Of(opNoneQ <br /> STATE ZJP <br /> Melling Address City <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Comp/ate if Billing Party is different from Property OWner or Responsible Party identified above. <br /> BUSINESS NAME Attention:orCere OlfJJptlGu=JeIJ <br /> GNVN'F tJ M/k'I`f 'V� <br /> Melling Atltlresa PHONE <br /> lot 5DWI KjF- Cow >J fsD • X175-�°W -3S 1 <br /> STATE ZIP <br /> CRY sr�1_` DSO Gi <br /> A,,,a=AfZADaRGWfor ireres`,and lI Charges OWNER FACILITYjBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOW LEDGhtENT: L the undersigned Applicant,certify that Ism the 0moar,Opernmr,AmhOdzed Agem,Ur RCSOnr15IJdC Porn'and 1 acknowledge that all Pe"O"FEFS, <br /> PENALTIES,EvmRCENENT CHARLES anWor HOURLY CHARGES associated With this project Will be billed tome at the address identified above as the ACCOUAT ADDRESS for this Site. I also certify that Hit <br /> information provided on this Application is true and correct;and that HII mutated 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 Reguludom. As the undersigned Dover,Operator,Authors ed AgeaL or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and AS resits,reports,and other envin emental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my represenhtive. <br /> APPLICANT NAME(PLEASE PRINT) c�� ��y—� !��NJ /� SIDNATURE <br /> TITLE <br /> —TAX IC I ILA - (901 03 $3 <br /> P�dr,L•� SsP Z(KU�T- TA <br /> prove,!B <br /> g� Accourdin Mae Processing Completed B ONs <br /> SfrE Mat"TION I AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PLAN PE <br /> FEE:; <br />