Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE Mit,wo ER FILE RECORD INFORMATION "I�aR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDK CASE#Saob(RG 383 UNIT IV <br /> OWNER FILE:COMPLETE 7HEFOLLOW/NG PROPERTYOWNER/NFORM.anON CHECKIF OWNER CURRENTLYONFILEW)ret EHD <br /> PROPerre OWNER NAME /�. f a C- 04) 5-cZ',La <br /> First MI Last PHONENUMBER <br /> BUSINESS NAME E-KAiLADDREW <br /> Owner Home Address <br /> City STATE ZIP'?zf 5-7q— 62W <br /> Owner Mailing Address <br /> Sat.P� <br /> Meiling Address City State zip <br /> CORPORATION INDIVIDUAL El HI <br /> PARTNERSP❑ FEGAoescY❑ OTHER <br /> SITE MITIGATION/_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP 4 WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> CFA�C,IL,ITY IDS INV# ACCOUNT ID PR#IRON AsSIGN1i0 EMPLOYEE LEAD AGENCY:EHD _RWOCB_DTSC EPA_ <br /> gTra�� l r3 3LFo�S Sz83A J00146va <br /> FACILITY FILE COMPLE7E7HEFOLLowNG BUSINESS/FACILITY/SITE/NFORMA77oN.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ZL <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BU9INEssJFAaUEIY/SITE NAME <br /> L <br /> SITE AOontEss 19 66 7 ^ CO16 eveLeA or ^ 1 SUITE# BUSINESS PHONE <br /> ClttL- / ; STATE Zq J 2rf <br /> BOARD OF SUPERVISOR DISTRICT <br /> Mg essifLOCATION CODE I I KEY1 KEY2 <br /> ailirAddrDIFFERENTfr Facility Address 1 Attention:o Care Of(qubbnaq <br /> Mailing Address City STATE Zip <br /> SIC CODE APN#O t(-OQO-03 COMMENT: <br /> G I-Ocf0 -O O pecI-1-5 �aR C-tCPgN5teev TU c)I(-cqo-O <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME (~ Attention:GrCyst(OQdrW19/�e n <br /> Iti <br /> Mailing Address r PHONE YK <br /> 03 5t- Ste 30o Solt <br /> CITY STATE Zip <br /> AGcoingrAOGaERR for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BIELING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ArYOCNTADORESS 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 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 lot...do.to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT As soon As it is available and al the same done it ix <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEAsE PRINT) 1�1.cC,..�- (�l{l�fs SIGNATURE r/" zo <br /> TITLE / / ` - TAX ID# <br /> Approved By Data Accounting OMce Processing Completed By �A - Data <br /> SITE MITIGATION AMOUNT/PAID DATEOFPAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEES 3?5 37r� 1 <br /> — I1—t 3 e l"e e , L(A �" r Ww Is I LC <br />