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San i-e(quin County Environmental Health apartment S/T.C— <br /> DATE z7- /Z MASTER FILE RECORD INFORMATION MFR <br /> GREENFORM <br /> SITE MITIGATION&LOP <br /> g2a <br /> g EXDU ON OWER ID# CAGE#• UNIT IV <br /> OWNER FILE:COMPL'E7F7HEFoO'LLO�WINO PROPERTY OWN ER INFORMATION.' CNECN/F DWS/N/E�/R/�CUHR£Nn.roR{Fn�£mn+EHD � <br /> PROPFJTI't OWNEN NAME L �.0 ,-1 Cry �/ L Pts �DI TS <br /> First MI Last PHONENuMBER <br /> BUSINEss NAME GMNLAODREss <br /> Owner Home Address <br /> CRY STATE ZIP <br /> Owner Meiling Address IC70­0 <br /> Mailing Address City (7 � <br /> � <br /> CORPORATIONt�I v INCINOUAL❑ PARTNERSHIP❑ FED AGENCY (J OTHER`-❑(" <br /> SITE MITIGATION,_ENVIRONMENTAL ASSESSMENT.X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE IINVISTGATION_LOP <br /> FACILITY ID# INv# ACCOUNT ID P <br /> 111: 11 ASSIGNED EMPLOYEE LEAD AGENCY:EHDL_RWQCB_DT5C_EPA <br /> Igz /0 <br /> FACILITY FILE COMPLETE THEFOLLOW/NO BUSINESS I FACILITY I SITE INFORMAr/ON: <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 /> BusINI:SEIFACIIJTYISDENAME S �a`pVr?- -z f/7 <br /> SR //EADDRESs ghoo //^•- ` l L.� ✓�✓lam Y,c/ SUITE# BUSINFSSPHONE <br /> CITY STATE tlJ\ /114 ZIP 1-15 3b <br /> BOAROOFSUPERWSOR DISTRICT ? LOCATION CODE 7 REPT REYZ <br /> Mailing Address/fDYFFERENTfrom Fuc//HyAddmsa Attention:orCare Of(opf/ona/) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# / l V __C) COMMENT: <br /> THIRD PARTY BILLING INFO: Complete)f Billing Party is different from Property Owner orfacility Operator identified above. <br /> Business NAME ( / Atfanaon:crCars,Of(opUbmu933J_33jr.O6n <br /> Mailing Address��/O & Ca/_s ( f)5-0 PHONE 210 &719 <br /> -23/ <br /> CITY !! K STATE jT rI ZIP g5L?33 <br /> 6GCDLdltAODBE>iT for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACENOWLEDGMENT: 1,the undersigned Appfirsnt,certify that 1 am the Owner,Operator,ac Andmrized Agent of this Business,and f admowledge that all PERMrr FEES, <br /> PENALTIES,ENFGRCEME,Vz CHARGE and/or ROURLYCHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRE$S for this site. I 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 JOAQUM COt1NTV 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 DEPPARTTTMMENTT as,soon as <br /> itisavailable and at the same time it is <br /> repirm <br /> provided AN army E(PLentafivI <br /> APPLICANT NAME(PtEABE PRINT) �CVp( ,(�,�`A/✓/!(/nQf.�' I SIGNATURE � I / •� <br /> TITLE �lj I D J 5'.J'� TAX ID# _ <br /> Approved By Data ( 1 Accounting OMee Proc rming Completed By Gab 7 <br /> SITE MITIGATION A••^i,uT PAID DATEOF=ENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORKPPLAN/P'�E <br /> FEE: 2 /5c) <br />