SITE INFORMATION AND CORRESPONDENCE_FILE 2

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San . uaquin County Environmental Health Loepartment N DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION & LOP SHAOEO AREAS FOR EHD nor ONLY OWNERID# CASE UNIT IV OWNER FILE : COMPLETE THEFOLLOW/NG PROPERTY OWNER /NFORMA TION: CHECMIFOWNERCURRENrzroNFILEWITH EHD PROPERTY OWNER NAME / FifatM! Last `PHONE NUMBER BUsINess NAME E-MAILADDRESS Owner Home Address City STATE ZIP Owner Mailing Address Mailing Address City State Zip CORPORATION El INDIVIDUAL (I PARTNERSHIP ❑ FED AGENCY ❑ OTHER ❑ SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP FACILRY ID # INV# ACCOUNTID PR*/ RO # T - � ap} P 04tl€ � ri:43 9 s i� `. FACILITYFILE COMPLETE THEFOLLOWINGBUSINESS / FACILITY / SITE INFORMATION: Is this a NEIN Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YEs ❑ No ❑ BUSINEsidFACILITWISRE NAME SITE ADDRESS SUITE# BUSINESS PHONE CITY STATE ZIP 90ARDOFSVPERV160RDISTRICT LoctsnoNCODE Kot Kut Mailing Address ifDYFFERENTfrom FaciltyAddress Attention: orCer s Of (optional) Mailing Address City STATE ZIP SIC CODE APN # COMMENT: THIR® PARTY BILLING INFO: Complete IT Billing Party is different from Property Owner or Facility Operator identifisdabove. BUSINESS NAME Attention: Crowe Of (Optional) Meiling Address PHONE CRr STATE ZIP Accou.VrANaaEss for.fees and charges OWNER FACILIN/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE Aic:"OyyrSDCMENT: 13 the undersigned Applicant, certify that I am the Owner, Operntory or Authorked Agent of Ibis Business, and I acknowledge tbat aD PERAHTFEE.Y, PEN.rLT1E9, 6rvvoxcesrEAT f-Y/ARGaS and/orPromaFCAGES associated with this operation will be billed to me at the address identified above as MeAccou"ADDREss for this site. l also certify thatail information provided on this application is true and correct' and that all regulated activities will be performed in accordance with ail applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and STATE and/or FEoenAL Laws and Regulations. As the undersigned owner, operator, or agent of the property located at We above facility/site address, 1 hereby authorize the release of 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 lime His provided to me or my representative. APPLICANT NAME (PLEASE PRINT) SIGNATURE TITLE TAX ID # Approved By Dole Accounting Once Proeeasind Completed By Date SITE MRIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT # CHECK # RECEIVEDBV WOAk PLANtPE - FEE: