BILLING - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department DATE5,�,V- MASTER FILE RECORD INFORMATION"MFR" GREEN FORM / SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER I D#Okh . ?/ -7/ CASE t��;o?I�� UNIT IV OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OW,lNER CURRENTLJYONF'ILEW/TH EHD � PROPERTY OWNER NAME +, C- flvN ,L ylc�te.; ,()(, 1 'r V'�� `t - First MI Last/1PHONENUMBER BUSINESS NAME n� / Y f1 ��'�'�i ty jJ -1 N C` E•MAILADDRESS �) i/lam J V l� 1"` Owner Home Address (�- city STATE /,u 7iP 9syo y Owner Meiling Address l, Melling Address City State Zlp ❑CORPORATION INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP `-� �I�z��/ ��INV#G�D� � AA_�,L/rID PR#!RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ 6 a 960 r Jr,71,JI �RaS3Q�� FACILITY FILE: COMPLETE BUSINESS J SITE/PROJECT INFORMAT/ON: 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 ❑ BUSINESS/FACILrY/SrrEJPROJECT NAME ") t . SITE ADDRESS/PROJECTLOCATION SUITE# BUSINESS PHONE STATE zip CtTy 5 i e c it=T�t� / C �4 el,,Z.(-) C E ODE KEYS KEY2 Melling 1f0/FFERENTfrom Fac///tyAddress Attention:orCare Of(opflona/J STATE ZIP Meiling Address City [SIC CODE APN# COMMENT: T$q (30-o2 THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. BUSINESS NAME _ Attention:orCare Of(opLfonalf Meiling Address PHONE STATE ZIP CITY AccounlrAaoREss for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING BILLWG AND COMPLIANCE ACKNOWLEDGMENT: T,the undersigned Applicant,certify that I mu the owner,operator,Anlltorized Agent,or Responsible Pari),and I aclmowledge that all P-rR. TFEL•s, , PEn:4L71Es,EnFoRCE,v@,,,T CHARGLf and/or HouRLt'CJmRG1's associated uith tills project trill be billed to me at the address identified above as the AccouyTADOXESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities trill be performed in accordauce pith all applicable SAN JO.;QUIN COumn,Ordinance Codes and/or Standards and STATE and/or Fm)ERaL Laws and Regulations.As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,I hereby authorize the release of any and all results,reports,and 011ier environmental assessment information to SAN JOAQUIN COUfVY ENVIRO ICNTAL HEALTH DEPARTMENT as soon as it Is available and at the same dine it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT):5G,:6&eb �p�q�a SOS SIGNATURE clollY� TAX ID# 7 C TITLE Approved By Dole Accounting office Procosaing Completed By Data SrfEMITI0ATI0N AMOUNT PAID DATEOFPAYtMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WO'R}KPLLAANPE FEE:S 34� 3�U l2^r-�y ewer. — 132 CvaIV�� 2�So