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San Jc*uin County Environmental Health De*IjAprtment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> Lo I / �-/0-W t� I SITE MITIGATION 8,LOP <br /> SHADED AREAS FOR END USE ONLY OWNER IDA CASE A UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NePROPERTY OWNER/NFORMAT/ON: CNECK/FOWNER CURRENTLYONF/LEW/TN EHD Er <br /> PROPERTY OWNER NAME \Af CS <br /> , =PCMIC ` i <br /> First M, Last PHONE NUMBER <br /> BUSINESS NAME _ E-MAIL ADDRESS <br /> e <br /> Owner Home Address <br /> 325 <br /> City STATE Zip q 5 av <br /> S ke,G CA <br /> Owner Mailing Address O <br /> Mailing Address City State ZIP 9;;-g <br /> a <br /> S Vu c. <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENvIRONMENTAL AssessMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVEIMQATION v LOP <br /> FACILm ID A INvA AccounlT IDSRO A �� <br /> 1..,x }3 <br /> ( s .a <br /> lt <br /> FACILITY FILE COMPLETE THEFOLLOW/NQ BU (NESS/FACILITY/SITE/NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExlsnNe Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No Bf <br /> BUSINESS/FACILITYISITE NAME <br /> Pac1(�; 1-5 r S�.Cd► pCrv., <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> 3 'o r <br /> CITY STATE Zip <br /> S VC,C, LA C>Ot <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:orCare Of(opHonW) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN A COMMENT: <br /> a8 -qoe) <br /> THIRD PARTY BILLING INFO: Complete/f Billing Party is different from Property Owner orFacillty Operator identified above. <br /> BUSINESS NAME i - Attention:orCare Of (optYonaQ <br /> Mailing Address <br /> P <br /> H <br /> 3 3 r; 5 5 3a��`�- - t�v <br /> Cm STATE LP,� <br /> AGffilMdQQSW for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMEM CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address Identified above as the ACCOUNTADDRESS for this site.I also certify that 211 <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 /> 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon u it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) <br /> ' � y\ iU�"� SIGNATURE <br /> TITLE Sk- Jr- }r TAX ID 3�—08(oSao(o <br /> Approved By Date Accounting ORice Processing Completed By Dste <br /> SITE MITIGATION AMOUNT PATO DATE OF PAYMENT PAYMENT TYPE RECEIPT A CHECK# RECEIVED BY WOR PcAH'P'�5 <br /> FEE:$ T <br />