Laserfiche WebLink
San Jc ain County Environmental Health C 3rtment <br /> DATE 3/3/11 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLYyl UNIT IV f <br /> OWNER IO# C 9E# <br /> i' <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMA N. CNECKtr OWN CURRENTZ YONF/LEwTH EHD El Q <br /> PROPERTY OWNER NAME <br /> l First Ml Last PHONE NUMBER <br /> 7 <br /> BUSINEss NAME EMAILADDRESS <br /> Owner Home Address <br /> 2 7G W & -�&4— <br /> city ST zip <br /> ra 7 C� , <br /> Owner Mailing Address <br /> Mailing Address City State TZjP 3 <br /> 7 <br /> ORATION El INDIVIDUAL PARTNERSHIP❑ FEo AGENCY❑ OTHER❑ 3{' <br /> i <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> 1 <br /> FACILITY I D# INV# ACCOUNT ID PR#I R011t AS SIGNED EMPLOYEE LEADAGENcY:EHD_RWQCB_DTSC_EPA_ <br /> Wk12 <br /> ' ACID' 3 b'IW <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but <br /> 'a�NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINEss/FACIUTYISITE NAME u �JN0[Ap ` —r^—n D^1 <br /> SITEADDRESS //j � W. SUITE# BUSINESS PHONE <br /> CITY STAT ZIP X✓7s0 <br /> BOARD FSUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address KDIFFERENTJSromFac111tyAddress Attention:orCare Of(opdona/) <br /> Mailing Address City STATE zip <br /> fff <br /> Iff <br /> fft�:� <br /> [tt <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (op •nailI D�I� <br /> SA� ra <br /> Mailing Address l „ Br` _ N Cut� / � PHONE S/O Y6(c) <br /> t+_� -7119 <br /> 1 1 j <br /> (/�(f ��I {0 �f 1D � 1 <br /> CITY ()Q,QancST / <br /> ZIP O 4 <br /> AL'GoLwrADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or;I ulhor;zce1 Agcnt or lids Business,and 1 acknowledge that all PER.wT FEES, <br /> PF_A'.ILTIF_S,F.,VTORCF.VEA'r CIL.tl?G£S•amltor HOURLYCILdRGU associated with this operation will be billed to me at the address identirted above os theACCOVATADDR£SS for this site. I also cel'Iify 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 an/or <br /> Standards and STATE amdfor FEIIEILV.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 nssessnuent information to SAN JOAQUIN COUNTY ENVIRONMENTAL IIFALTIJ DEPA NT as soon as i[is. ••liable and at the same time it is <br /> provided to me or my represcntntive. <br /> APPLICANT NAME(PLEASE PRINT) VUS�161 erG'L SIGNATURE <br /> TITLE {ten ifl rZJyl tn�jY1 f C TAX i D# Ii <br /> 1i�� 11J C j <br /> Approved By Dato Accounting flico Procosaing Comploted By Dote ! <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br /> --- — — — — �1_ --1 ! <br />