Laserfiche WebLink
San Jc,.,ain County Environmental Health De,,,,rtment <br /> tl <br /> DATE11 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> d k /a T � SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDR CASE# UNIT IV <br /> OWNERFILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAwm CHECKiF OWNER CURRENTLYONF/LEWITHEHD®" <br /> PROPERTY OWNER NAME V V l I e- t N / <br /> VVV VVV First 4 Ml l Last `PHONE NUMBER <br /> BUSINESS NAME � _ /^ E-MAIL ADDRESS S t S I - A f c) s (-J� S <br /> Owner Home Address <br /> _ Sas <br /> City _ STATE ZIP Sq S av" <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> P 9�av <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID R y'g <br /> INv# ACCOUNT ID PR#IRO# fldr + R <br /> fX a�S" ati rna "rC* 4k. y <br /> FACILITY FILE COMPLETE THEFOLLOW(NG BUSINESS/FACILITY/SITE INFORMAT/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 /> BUSINESSIFACILITY/SITE NAME <br /> Pax 1;; t 1-� r c, S Q,ctl� %"dv. <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE LP <br /> S G I�Hw� C-A G <br /> BOARD OF SUPERVMOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address/10/FFERENTfivm Feci/ityAddress Attention:or Care Of(options/) <br /> Mailing Address City STATE ZIP <br /> f�� <br /> APN# COMMENT: <br /> -.]I U8 -400 - 09 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME �V Attention:orCare Of (option/J <br /> GI�V� t <br /> Mailing Address PHON <br /> 3 3 3 v r;v 5 5 f3o� vv <br /> Cm STATE 7Jp <br /> C�k <br /> Accom LBDDRESs for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERWTFEES, <br /> PENALTIES,ENFORCEMENTCHARGEs and/or HouRLYCHARGES associated with this operation will be billed to me at the address Identified above as the ACCOUNTAOURESS for this site. I 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 /> 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 as it is available and at the some time Itis <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) 1 `i` I U�— SIGNATURE <br /> TITLE TAX ID# <br /> C'k'a'� 3-3 0'?-, 0(o <br /> Approved By Date Accounting Office Processing Completed By Date <br /> 317E MITIGATION AMOUNT PAID GATE OF PAYMENT PAYMENT TYPE RECEIPT R CHECK# RECEIVED BY >WbRk Piika <br /> FEE: <br />