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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D,ARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION 81 LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITH EHD PROPERTY OWNER NAME t _._--EL - FIRST MI LAST PHONE NUMBER BUSINESS NAME n E-MAILA`DDRESS OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS �'/ I/,` '� MAILING ADDRESS CITY ST TE ZIP I ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION__LOP FACILITY ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA I FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No'-Y IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No BUSINESSIFACILITYISITEIPROJECT NAME SITE ADDRESS I PROJECT-vw-�TION • \1, r, l✓ 1—. SUITE# BUSINESS PHONE V' / A , 0 ./ TE ZIP CITY �+ BOARD OF SUPERVISOR DISTRICT LOCATION CODE 7 7KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITYDREBS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE ZIP SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) r_; L MAILINGADDRESSPHONE / ,;C /(�� 1.39 CITY A �� r STATE ZIP c � I l / ) FACC7ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINQO BILLING AND COMPLIANCE ACKNOR'LEDGM1IENT: I,the undersigned Applicant,certify that I and the Owner,Operator,Authorized Agent,or Responsible Pm9P and I acimon'Iedge that all PEIIA11T FEES, PENALTIES./:NFORCEAIENT CHARGES and/or HOURLYCILIRGES associated with this project will be billed tonic at the address identified above as the ACCOUNTADDRESS for this site. I also eefdfy that all information provided on this application is true and correct;and that all regulated activities still be performed in accordance with all app hJble SAN JOAQUIN COUNTY ORDINANCE CODES mut/or STANDARDS and STATE and/or FEDERAL Laivs and REGULATIONS. As the Undersigned Onvier,Operator,Authorized Agent,Or Responsible P ' ov f oder facility/site address, hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY vim NIdENTAL HEALTH DCPA ,IENT as soon as it is available and at the same time it is provided to mC or/ /v rere / APPLICANT NAME(PLEASE PRINT J/L)L�' scnI4vf,/-L / SIGNATURE t • / TITLE APPROVEO BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY APPZVEDATE =FIE AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY -WORK PLAN PE