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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM 4/2 8/14 SITE MITIGATION& LOP SHADED AREAS FOR EHD USE ONLY OWNER IDS /. �J�/10/3//J J CASES UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: OmEcKiFOwHERtaCURRE/VTLYOHFFLEwiTH EMD PROPERTY OWNER NAME �09) 468-6000 FIRST MI I LAST PHONE NUMBER BUSINESS NAME E-MAxAODRESS San Joaquin General Hospital OWNER HOME ADDRESS 500 W. Hospital Road CITY French Camp STATECA zip 95231 OWNER MAILING ADDRESS 500 W. Hospital Road MAILING ADDRESS CITY STATE ZIP French Camp CA 95231 ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP 0 GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITYIDi iNVtl AxouNTID PRf# =61ONEDEMPLOYEE LEAD AcENOY:EMD�RWQC6DTSCEPA FACILITY FILE:COMPLETE BUSINESS I SITEJ 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 BUSINESSIFAoKJTYISnWPROJWTNIWE San Joaquin General Hospital SITE ADDRESS I PROJECT LOCATION SUITE 0 BUSINESS PHONE 500 W. Hospital Road CITY French Camp CA ZIP 95231 BOARD OF SUPERVIbOR DISTRICT LOCATION CODE KEYS KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILFTY ADDRESS ATTENTION:OR CARE OF(OiPrIDNAL) MAIUNG 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(OPriox&) MAILING ADDRESS PHONE CITY STATE LP ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER . FACILITYIBUSINESS❑ THIRD PARTY BILLING❑ BILLING AND COMPLIANCE ACKNOWLBDGUM: I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsibk Party aid 1 aclmoMedge that all PERIHT FEES, PE%ALTTES,E'1'FORCE1fE.%TCHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the Arcot sT ADDRESs ford*site. 1 alto certify that aB information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JoAQLT-4 COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS.As the undersigned Owner,Operator,Authod-.ed Agent,or Responsibleor the project located above under facility/site address,l hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY 1ENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. APPLICANT NAMe(PLeABe PRINT) !J A V I, CA S--A&,/Iq SIGNATURE TITLE CA T I'l A-c- A RV Xi 6;'S /��/L//NJS =�L i"[, TAX ID is APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION A PUNNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CIIMICS RECEIVED BY WORK PLAN PE FEE: T.4. 3 715— op