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San J/ uin County Environmental HealtV apartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION, CHECKIF OWNER CURRENTLYONF/LE WITH EHD El <br /> PROPERTY OWNER NAME - ( 916 )640-1500 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME FIVE STAR BANK,A CALIFORNIA CORPORATION E-MAIL ADDRESS IBECKWITH@a FIVESfARBANK.COM <br /> Owner Home Address 2400 DEL PASO ROAD <br /> City SACRAMENTO STATE CA ZIP 95834 <br /> Owner Mailing Address c/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 ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC EPA <br /> IToq ][: INV# PRvSZAo8N — <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION. <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES O NO ❑ <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICTIF / LOCATION CODE / KEY I KEY2 <br /> Mailing Address ifD/FFERENT from Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> 11 13 -4)55' -o <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME /� ^ Attention:orCare Of (optional) <br /> Mailing Address Ili l 1 o6-e-- PHONE <br /> CITY �, A O�Sto <br /> � nSTATE ZIP <br /> ACao TADDREss for fees and charges OWNER FACILITYIBUSINESS l— THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERLIIT FEES, <br /> PENAL77Es,ENFoRCEMENTOiARGEs and/orHouRLY CHARGES 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 it is <br /> provided to me or my representative. 1 <br /> APPLICANT NAME(PLEASE PRINT) V\�A 1- 0�G�Q� SIGNATURE <br /> CL <br /> �j <br /> TITLE TAX ID#v�av�c,� �� Lf - 0-2>�9 H <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY p W K PLAN PE <br /> FEE:$ J{d 3lV ll•2��1� C l�.� _ 4-o8? &V to toU <br />