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San Joal-uin County Environmental Health epartment <br /> DATE �; <br /> WIh_I ER FILE RECORD INFORMATION�� R" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# 7l "/ CASE# "'�J/ D� {p 3 /�� UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY (OWNER INFORMATION.'1`- CHECK/F OWNER CURRENaroNF/LEwm EHD <br /> PROPERTY OWNER NAME l� LV hi <br /> ll�J First MI 1 Last PHONE NUMBER <br /> BUSINESS NAME � EMAIL ADDRESS <br /> Cajr'A�() �� <br /> Owner Home Address I^ 1 1 l G-V <br /> City �(AI C A $TATE Pip <br /> a 's 3�G <br /> t✓ �n <br /> Owner Mailing Address AIC t <br /> 186 A6 <br /> Mailing Address City ➢'1 r cO State Zip <br /> CORPORATIONElINDIVIDUAL❑ C! l PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNT ID o# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA_ <br /> 19-73 9 <br /> FACILITY FILE COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No IR <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINEWFACILITY/SITE NAME <br /> SITE ADDRESS I� - l.Nl� 1 1 `I BUSINESS SUITE# BPHONE ocf Ws-5-616 <br /> CITY � � STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 <br /> Mailing Address!fD/FFERENTirom Fac!/KyAddraw Attention:orCare Of(opdona/J <br /> {✓1 <br /> Mailing Address City STATE ZIP <br /> 1 <br /> fft: <br /> fft:: <br /> COMMENT: <br /> 1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME `"A .�— / Attention:orcare Of(opaw,aq <br /> Mailing Address � n I?q/ PHONE � � ���� <br /> CITY t�d � (/ ST RTE ZIP <br /> AaaovffADDREss 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 PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACICOVNTADDRE4S 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 ve acility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ARTM T as soon as it is available ad at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) 21c <br /> �Cn SIGNATURE <br /> TITLE TAX ID#'� C <br /> Approved By Date Accounting Office Processing Completed By Date L(�✓��� <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PQLA[N�PE <br /> FEE:$37S•� x,75- x� I0/Z0/I� tom- 33315 IAJ 9 I .JC <br />