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San ., .juin County Environmental Healt, apartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> OWNER ID# CASE �f SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY # ,Sfix=-71 O/ UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER AtFORMAT/ON. CHECKIF OWNER CURRENTLYONF/LEw1TH EHD <br /> PROPERTY OWNER NAME ` <br /> ( 916` 6'4,0_1 CJ00 <br /> First MI Last `PHONE N/UMBER <br /> BUSINESS NAME FIVE STAR BANK,A CALIFORNIA CORPORATION E-MAIL ADDRESS IBECKWITHCIc FIVESTARBANK.COM <br /> Owner Home Address 2400 DEL PASO ROAD <br /> City SACRAMENTO STATE��-T ZIP 95834 <br /> Owner Mailing Address o BUZZ OATES MANAGEMENT SERVICES <br /> Mailing Address City 8615 ELDER CREEK,SACRAMENTO State CA ZIP 95828 <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# ACCOUNT IDElpeol <br /> R#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DISC EPA <br /> 'foH <br /> �L;4�0#57 A��vz57 SZ�,o87 Ju1fNtiN — — <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 a NEw TYPE of regulated Business? YES ❑ No JK <br /> BUSINESSIFACILITYISITE NAME <br /> SITEADDRESS SI/17 Af J / / SUITE# BUSINESS PHONE <br /> CITY /_^. STATE ZIP <br /> C`J PITO Y�.i <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE KEY1 KEY2 <br /> Mailing Address WDIFFERENTfrom Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> 13�-oSS-al <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME C a� ^� � Attention:orCare Of (optional)Mailing Address i i i- L o r a— \'��N^ �� SUtt` PHONE <br /> CITYSTATE ZIP <br /> o.�'S-f'o l.n�p, <br /> AccouNTAooREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77Es,ENFORCEMENT CHARGES and/or HouRLYCILIRGES associated with this operation Will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all <br /> 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 <br /> Standards and STATE and/or FEDERAL 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 assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> provided to me or my representative. I 1 I' <br /> APPLICANT NAME(PLEASE PRINT) �J L0.V1�1� L- 1 ov'As y SIGNATURE <br /> TITLE ,/�/' _ 1 TAx ID# <br /> Approved By I Date Accounting Office Processing Completed By Date <br /> SITE MITIGGATION AMOUNT PAID DATE OF PAYMENT PAAYMENTTYPE RECEIPT# CHECK# RECEIVED BY p WORK <br /> PLAN PE <br /> FEE: �!� 3 lU �I•Z� ! 1 l:fl�L�r. ,I/Nk t GU <br />