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San Joaquin County Environmental Health Department DATEMASTER FILE RECORD INFORMATION"MFR" GREEN FORM f I N I Q �/ SITE MITIGATION&LOP SHADED AREAS FOR EHO USE ONLY OWNER ID# CASE#SRL)0!' Ono UNIT IV SQm 07 OWNER FILE:COMPLETEPROPERTY OW��NER/RESPONSIBLE PyARTY INFORMAT/ON: CHECNIF OWNER CURRENTLYONFILEW1rH EHD E1 PROPERTY NAME -}., v_ 4Jl%�t ►�,L t�y�� Iiztk-2 � /L'-j) ylC(r —L/��(� First MI Last PHONE NUMBER BUSINESS NAMEfb Qe -ry N E-MAILADDRESS �<rq/,43o-) iit � Owner Home Address C D& ti T14 C 6 L City Owner Mailing Address Meiling Address City State Zip ❑CORPORATION �`INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# AccouNr lD PR#IRO# AS6IGNED EMPLOYEE LFaD AGENCY:EHD_RWQCB_DTSC_EPA FACILITY FILE: COMPLETE BUSINESS/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 ❑ BUSINE99/FACILITY/SrTE/PROJECT NAME SITE ADDRESS/PROJECT LOCATION SURE# BUSINESS PHONE CITY STATE ZIP BOARD OF SUPERVISOR DISTRICT J LOCATION CODE KEY1 KEY2 Meiling Address if DIFFERENT from Facility Address Attention:of-Care Of(optional) Mailing Address City STATE ZIP SIC CODE APN# 30COMMENT: X34- ( . 02 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 ACCOtINTADDREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING III LIANG AND COMPLIANCE.ACKN'OWLEDGMENI': I,the undersigned Applicant,certify that 1.1111 the Owner,operator,Authorized Agent,or Responsible Daily and I acknowledge that all PEP IIIT PELS, PL•',%'4LT/Es,E,YFORCEAII':\'TCH.IRGES a11dloi-FIOURL)'CIL4RGLS aSSOCiated ivith(Ills prOJCct 1t'ill he billed to me at(lie address identified above as the ACCOU.VTADDRESS fol'this site. I also certify plat all information provided on this application is true and correct;and that all regulated activities will be performed in accordance)ith all applicable S.A.N JO.AQInN Cou,,rr 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,I hereby authorize the release of any and all results,reports,and other enviroumental assessment information to SAN JOAQUIN CO Y ENVIRO tCl 'NTAL HEALTH DEPARTMENT as soon as it Is available and.1t the same time it is provided to me or my representative. \. APPLICANT NAME(PLEASE PRINTJ�A&t'g �. 7e�'n0.I S ctn SIGNATURE ^�- TAX ID# TITLE Approved By Dote Accounting office Processing Completed By v Date SREMITI?DATIONJAtMOTUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHE( # RECEIVED BY WORK PLAN PE FEES �Ut2-1--�� er .c — / 32` �uw�� l