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v � SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATEIF MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE#` R�u� UNIT IV OWNER FILE: COMPLETER ^ PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: 7 CHECK OWNES CUR R ENTLY ON FILE W?H EHD PROPERTY ONNGR NAME "C•,.. Z U VL"V't (7-14 FIRST MI LAST PHONE NUMBER BUSINESS NAME i , E-MAIL ADDRESS C"S a �j-tY U C. +�t:. Y C' S v civ\. Y t. of vi N't�-'A C Y%k k S c> . OWNER HOME ADDRESS CITY STATE ZIP OWNER MAILING ADDRESS 15 e- MAILING ADDRESS CITY ; � \ M1 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# ACCOUNT ID PR W RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA FKD 5,3!5 I FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: 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/FACILITYISITE/PROJECT NAME .)`A \ �\5 C' y SITE ADDRESS I PROJECT LOCATION - SUITE# BUSINESS PHONE I S S O L .rLcJluSi r CITY STATE ZIP BOARD OF SUPERVISOR DISTRICT I LOCATION CODE ! KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS 111 ATTENTION:ORCARE OF(OPTlomL) MAILING ADDRESS CITY STATE ZIP SIC CODE APN# COMMENT: V THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME c� ✓CC, ATTENTION:ORCARE OF(OPTloNAL)S�o \vc.-5�c>_�,-tel .J✓vL MAILING ADDRESS PHONE 4 0 ��Dov zil C ti° \� 'td K -�-1�Ci - 5 5 3 3 CITY \ STATE LP 0 ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,.4utliorized.4gent,or Responsible Party and 1 acknowledge that all PERMIT Fees, PENAI.Tmv,ENFORCEMENT CHARGES and/or HOURf.YCHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTADDRFm for this site. I also certify that all information provided on this application is tine and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Respon.sihle Party for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and Other environmental assessment information to SAN JOAQUIN COUNT'ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. �•,__ 1 APPLICANT NAME(PLEASE PRINT) d�K"(� SIGNATURES TITLE •-� �'A'`\' TVVJ l TAX 10# �j APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MI GTION AMOtr�7T P to DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORQK PL�AN)PE FEE:; �� /� �'2�'� /01: �OKKI �I✓`�