BILLING - Laserfiche WebLink

Home Browse Search

to San Joaquin County Environmental Health Department DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM IL-- SITE MITIGATION& LOP SHADED AREAS FOR EHD usE ONLY OWNER Io# CASE# UNIT IV OWNER FILE:CoMPLETEPROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK/F OWNER CuaREHrcroHFILE wirH EMD PROPERTY OWNER NAME •�K.0 Firsf 11✓��"' M1 Last PHONE NUMBER BUSINESS NAME EMAIL ADDRESS 5 CST b raM.45,co A K Owner Home Address City STATE ZIP Owner Mailing Address Melling Address City YJ � IIA J state A ZIP ^. -Z2 v CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNTIO F PR Oflfbt AB!lIONEOEMPLOYEE LEADAOENOY:EHD%RWQCB_DTSD_EPA _ li FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT INFORMATION: Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No`� IS this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YEs ❑ NO 19 BUSINEsslFACILITYISITEIPROJECT NAME Y lI SITE ADDRESS I PROJECT LOCATION V V IU SUITE# BUSINESS PHONE l Z I nw+. P,cr �.>✓c,�-- N 9g�4'-0�i� o t 2— CITY � U( I STAT ZIP ^ BOARD OF SUPERVISOR DISTRICT1 :;;(�1-- LOCAITIIION CC;O•`D_lE. �/�l KEY1 KEYZ J Mailing Address HDIFFERENrfrom Faci/ifyAddresa / L Attention:or Care Of(optional) T S"fY:2fL l Meiling Address City I STATC%A ZIP Q 2 3 CiAn. RIC CooE APN# 1[tf THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. BUSINESS NAME Attention:orCare Of (optional) Mailing Address PHONE CITY STATE ZIP AccmmrADDRESS for fees and charges OWNER ,- FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Parry and I acknowledge that all PERMIT FEES, PE,v,U.TTEs,ENFORCEmEM CHARGES and/or flouRLYCH,tRGEs associated with this project will be billed to me at the address identified above as the ACCOUNTADDRE.YS for this site. 1 also certify that 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 Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMEiN-FAL HEALTH DEPARTNIENT as soon as it is available and at the same time it is provided to me or my representative. / APPLICANT NAME(PLEASE PRINT) ") �r —J�.v 111 fN SIGNATURE TITLE 1(` TAX ID# Q4-11 Z Approved By Date I,U 1 Al , Accounting Office Processing Completed By Date SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CCHECC'K/n�# f,,, RECEIVED BY W'7ORGKlPLAN f PPE FEE: i V cfa. — Z ZA1`J--