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4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# D�/�/lI (>h rL. '+ASE# UNIT 'V OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE P✓✓✓ARTY INFORMATION: CNECK/FOWNERJSCURRENTLYONF/LEW/TH EHD PROPERTY OWNER NAME FIRST MI LAST PHONE NUMBER BE-MAILADDRE56 USINESS NAME 56,4 �I`c I C a � SCC_ 0�/ OWNER HOME ADDRESS CITY ZIP OWNER MAILING ADDRESS r•L C� rd MAILING ADDRESS CITY ST EA ZIP ^/ ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP VERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNTID PR#IRO# ASSIGNEDEMPLOYEE_; FLEADAGENOY:_EHD X 'RWQCB_DTSC_,EPA ofDD4o 0c►�'�'{ FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW OPE OF WORK? YES ❑ No BUSINESSIFACILITYISITE/PROJECT NAME ti ��/` SUITE# BUSINESS PHONE SITE ADDRESS I PROJECT ZIP CITY �STpTE rMAILING F SUPERVISOR DISTRICT LOCATION CODE KEW/ KEY2 ADDRESS,IF DIFFERENT FROM FACILITY DPRE83 ATTENTION:ORCARE OF(OPTIONAL) \— STATE ZIP MAILING ADDRESS CITY ------------ F=77==APN#I . COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. (J ATTENTION:ORCARE OF/(OPTIONAL) BUSINESS NAME VA MAILINGADDRESS ILS PHONE C CIN / V _ STATE ZIP o ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLINCO— BILLING AND CO,%TPI,IANCE ACI(,NONLEDGaIENT: ],the undersigned Applicant,certify/hat I am the Owner,Operator,Aatborized Agenf,o•Responsible Ponh,and I acknowledge that all PERMITTEES, PEN.ILTIES,F.A'FORCEAtEN7CHAfiGf:S and/or HOUItLT CKdEGES associated with thus project gill be billed to me at the address identified above as the ACCOUArADDRESS for this site. I also cerdry that all information provided on this application is true and correct;and that all regulated activities Trill be performed in accordance Trith all app ie ble SAN.ionQuw COUNTY ORDWANCE Cones and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Annthorized Agen,or Responsible P j fPr the project located abov finder faciilty/site address,I hereby authorize the release of any and all results,reports,and othjen 'ronmental assessment information to SAN JOAQUIN COUNTY VIR NDTENTAI.IIeALTFi DEP IISNr as soon as itis available and at the same time it is provided to mc4r-FyY represent 'v. APPLICANT NAME(PLEASE PRINT SIGNATURE TITLE TAx ID# -� � ( , U 111 GG J f PROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY TE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVEDBY WORK PLANPE E:$�� " �� ✓ —