Laserfiche WebLink
San Jo ,.Ain County Environmental Health C _ artment <br /> DATE 04/1�1 7-01 MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> / I SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OVVNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHEcKiF OWNER CURRENTLYOvFicewlmEHHD <br /> PROPERTY OWNER NAME aaN_ Ml ` <br /> ! /\ (05 E—S 9 0Y <br /> First Last PHONENUMBER UUU <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> 68 1of.s 17. R� <br /> Mailing Address City State Zip <br /> W. M � 4-0 r\ AAA <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION X ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALTY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INv# ACCOUNT ID PR#IRO# ASSIGNED EMLYEE —RWQCB��DTSC—EPA <br /> LEADAGENCY:EHD <br /> bas � 21 dB o�8 <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAwN. <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 ❑ <br /> BUSINEss/FACILITYtSITE NAME <br /> SITEADDRESS SUITE# BUSINESSPHONE <br /> g19 N. L;p (zoy 741- p 4L <br /> CITY 1 ^ STATE ZIPCN q <br /> �ZD2 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address KD/FFERENTfroddress Attention:orCare Of(optional) <br /> Mailing Address City dW STATE ZIP <br /> [!t.DE APN# COMMENT: <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 p (opUona/)sl`nEC l�w� r•X sr.c. :1 V. e- <br /> Mailing Address PHONE <br /> 2.;,7S <br /> Iz I E7. <br /> CINSTATE ZIP <br /> F<C� CA 93-+Z0 <br /> ACwUwADDRESS for fees and charges OWNER FACILITYIBUSINESSTHIR ARTY BIL <br /> BILLING AND C:OMPLIANCF.ACKNOWLEDGMENT: 1,the undersigned Applicant,certifv that I m the OR�ner,1lperamr,or Authorized Agent of this Business,and 1 acknowledge that all PERM17'/EFs, <br /> PIiNAtms,ENFORc'FALEM CHARGES and/or/RIURLYC7L4R,f?S associated with this operation I be billed to me at the address identified above as the Ac'COt/NTAnnRF_CC for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated act ities will he performed in accordance with all applicable SAN JOAQUIN COUNII'Ordinance Codes and/or <br /> Standards and STATE:and/or FEDERAI.Laws and Regulations. As the undersigned owner perator,or agent of the propeM located at the above facility/site address,I herebv authorize the release of <br /> any and all results and environmental assessment information to SAN JO.AQUIN CO.NTY ENVIRONMENTAL HEALTH DF.PAR7�1' 'T as soon s tis available and at the same time it is <br /> provided to me or my reprcc, ntative_ <br /> • <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE P / �w C C TAx ID# 01(�.-Z�-( <br /> Approved By 1DaateAccounting lice Processing Completed By Date l <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />