Laserfiche WebLink
r7- <br /> SAN JOIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> IMATE MASTER FILE RECORD INFORMATION "M R" GREENFORM <br /> 3�•/3 SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USEONLY OWNER IDS CASE#9Z00 G7([7 /rJ UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CNEyCR�IPaOwLN�ER//sLCJuRReNrcvoN FILE WITH EHD <br /> PROPERTY OWNER NAME Olt 5(L q I Q,y- (.�$t/T K�St I r • I�� <br /> IRsr MI LAST PHONE NUMBER <br /> /I E-MAILADDRESS <br /> BUSINESS NAME <br /> Mw1lr I'S fwvtis'FN+tiwJs In e.. hawiMlera ✓ co oC +P`u �� ' �vwr <br /> OWNER HOME ADDRESS <br /> STATE ZIP <br /> CITY <br /> OWNER MAILING ADDRESS 3250 Wes-f- <br /> 5 �-. WFw! Ani <br /> MAILING ADDRESS CITY fr-c'k cn <br /> S ZIP <br /> *ORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# Inv# ccouttT PR#1 O ASSIGNED EMPLOYEE LEAD AGENCY:EH D�RWCtCB_DTSC_EPA_ <br /> 2-` )-q AR o.037/ 52 70 J0 Na <br /> FACILITY FILE:COMP Eft SITEI OJECT INFORMATION: rp <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BYTHE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No f% <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? ///VVV YES ❑ NO '4 <br /> BUSINESSIFACILNYISITE/PROJECT NAME ��G� <br /> SITE ADDRESS/PROJECT LOCATION 1 SUITE# BUSINESS PHONE <br /> 325D k/e�f �yt,wl,.vt�✓ �.-a-K.C� <br /> CIN STATE zip �' ^ <br /> BOARD OF SUPERVISOR DISTRICT O`✓�1vyrV}V//•LOCATION n,CODE O / KEY'I L/14KEY2 !/V <br /> MAILING ADDRESS,IF DIFFERENT FROM FACIILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> SIC CODE APN# 682-yoo -(':>g COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME (,, ATTENTION:ORCARE OF (OPTIONAL) 7f[,L(/.__ (�(A V G l— — <br /> S'V- I Y O✓tVP�w' YNCi . � <br /> MAILINGADDRESS PHONE <br /> 3330 CjlLWGr-o0 PAA k pfVe- �tlt 5so S3D-67�-60 8 <br /> ATE ZIPgs6 8 L <br /> CITY <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> Bu.l.mC AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,cerfify that!am the omne,operator,AuOmriieAAgen1,or Responsible Parry and 1 acknowledge that all PERMIT P'EEC, <br /> PL III IIES,ENEORCEATEN9CHARGES and/or 110URLYCHARGEN associated with this project will be billed to meat the address identified above as the AC(OuNY AnORct's for this site. 1 also certify that all <br /> 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 /> S I a%I):\RDS and STATE and/or FEDERAL Laws and REGULATIONS. As the Undersigned 0...er,operator,AaUoriLed AgenA or Responsible Party for the project located above under facility/site address,1 <br /> hcivIO authorize the release of any and all results,reports,and Other environmental assessment information to.SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available <br /> :unl at the Same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) fAhe*i I t� F4 SIGNATURE <br /> TITLE TAX ID# <br /> APPROVED BV DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY / D GDATE O <br /> SITE MCITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ <br />