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San Joaquin County Environmental Health Dertment <br /> DATE / MASTER FILE RECORD INFORMATION`IMFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> B R O OwNERIDIi CASE - .. UNIT IV <br /> OWNER FILE:COMPLE7E 7HEFOLLOWING PROPERTY OWNER INFORMA7-107N: CNECNlF OWNER CUR�FE(N,T�LY�{7ONFlLEYY11I/JN/EHD <br /> PROPERTY OWNER NAME � "_ �o�y l '. ✓ �+.V��� ! �� <br /> First M1 Last PHONENUMBER - - <br /> BUSINESBNAME E-MAILADDRESS <br /> � one- mss . <br /> Owner Home Address <br /> G,f $TATE ZIP <br /> Owner Mailing Address 54-7 f'T- r_v 1` <br /> V �P `U <br /> Halling Address Cfiy - <br /> Sia J <br /> If�%t- <br /> t CORPORATION❑ INDIVIDUAL - PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SIT[MMOATION_ENVIRONMeNTAL AssesmeNT VOLUNTARY CLEANUP—WATER QUALn'Y HW PIPELINE INVISTIOATION_Lopey <br /> 'FACIiATYIDO INV# All O.NTIO .PROIROS ASSIGNEDEMPLOYEE <br /> LEAD AGENCr:EHD RWOCB_OTSC 'EPA— . <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT?" YES ❑r No Rr <br /> Is this an ExISTING Business LOCATIoN but a NEW TYPE of regulated Business? YES [] No <br />�. BUSINEss1FACILITYISITE NAME ��_ Ot/1D s S'1. <br /> i SITE ADDRESS <br /> C.•� ` sulre# BuSIN HO�� q, <br /> CRY STATE, Zip�- �3 rL(o <br />.. BOARD DP SUPERVISOR DISTRIDT a S LOCATION CODE Q KEY1 - KtYL . <br /> Mailing Address HD/FA&WNTfrom Fac/ft Address Att nwn:areare Of(,V&nW) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COWENTC <br /> i <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of.(opLbaaq <br /> {L� Mailing Address f� -� ^ PHONE2—Q el <br /> Cm STATE. ZiP <br /> ACCWNTADDRESS for fees and changes OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: ],the undersigned Applicant,certify that I am the Owner;Operator,or Authoriyed Ageu!of this Business,and I acknowledge that all PEKwiTFEE.c, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLPCHARGES associated with this operation will be billed tome at the address identified above as the AccouNTADDREss for this site. I also certify that <br /> nil information provided on this application is true and correct;and that ail regulated activities will be performed in accordance with all applicable SAN JOAQGIN COQNTY 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 facilitylsite ess, ere c the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR HENT as soon a it is available and at the a time itis <br /> Il provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) ry}t �S ' , <br /> [�J rLJ'` SIGNATURE <br /> I TITLE TAX ID# <br /> i Approved B Date Accounting 611106 Prca"I Com letsd B Data �A2_ I D <br /> - <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT CHECK# ;,'RECEIVED BY .WORK PLAN PE <br /> FEE. <br />