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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dr.PARTMENT <br /> DATE M§,dTER FILE RECORD INFORMATION `,.IIWR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHO USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLE'T'E PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK iF OWNER Is CURRENTL Y ON FILE W/rH E H D <br /> PROPERTY OWNER NAME W GS PO-4- <br /> I,I)--Cd yl V d 4 L f?q— I <br /> Rsr M/ LAST PHONENUMBER <br /> BUSINESS NAME E-MAIL ADDRESS w>�,�6e- Y-S Sr`�.-�S�-w�.�f�,-�s T��� haw�f�r-�w-�cd <br /> OWNER HOME ADDRESS <br /> CITY STATE ZAP <br /> OWNER MAILING ADDRESS 2 2 CD G L <br /> .7 J W s7 lam w�-� r.-a�.►1� <br /> MAILING ADDRESS CITY � $� zip <br /> LIA CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONS113LE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/ ASSIGNED EMPLOYEE LEAD AGENCY:EHD�f_RWQCB_DTSC_EPA_ <br /> HRc�3 3 7v Jo,(Ax <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 /> BUSINESS/FACILITY/SITE/PROJECT NAME <br /> S /`Go <br /> SITE ADDRESS/PROJECT LOCATIONSUITE# BUSINESS PHONE <br /> 3 2 Sd kJc'F �,a-wt.►rlt,✓ �-�.v�� Q <br /> CITYS / r � STATE ZIP q s� <br /> BOARD OF SUPERVISOR DISTRICT •J fes/,('/JLOCATION CODE KEYS {i/I�AKEYY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> ffO DE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME i ` �I � ATTENTION:ORCARE OF (OPTIONAL) (�� <br /> MAfLINGA00RESS 3 330 0g-*ne 'oo Pa, k �/ <br /> PHONE <br /> �.�;w� �L;�C r�o S3D-6 7(p—6009 <br /> CITY /,/J1-/� �,�/� Q <br /> ca-pF 1 e' (� C, ATE zip <br /> S6 8 Z <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the(hvner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMIT EFEV, <br /> PLAAL IFS,ENT-oRC.ERfL-NT CHAHGFB and/or HouRIYCHARGEs associated with this project will be billed to me at the:address identified above as the ACCo[WTADURF4s 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 /> SI ANDARUS and STATE and/or FEDERAL.Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTv ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) !,n J` /O 4 SIGNATURE <br /> TITLE TAz ID# 3-_p S?6 8106 <br /> APPROVED BV DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />