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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM 17 SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER IDS CASE s UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF,jOWNER ISCURREHTLVONFKEwTTH E H D PROPERTY OYYNCRAME FIRST Ml LAST PHONE NUMBER BUSINESS NAME ` +y,, E-MAIL ADDRESS ` �} �\ OWNER HOME ADDRESS CCS City STATE LP OWNER MAILING ADDRESS n 5 C> rl�I o.tnc.� a MAILING ADDRESS CITY ` 1' �` ` STATE zip LA —7 Q 55-PORATIINI ❑INDIVIDUAL T,❑�`PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY ID EMPLOYEE LEAD INvK ACCOUNTID FG �l AGENCY:EHD^RWQC$_OT8C_EPA_ FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: ISTHIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Nr IS THIS AN EXISTING PROJECT LOCATION,BLIT A NEW SCOPE OF WORK? YES NO ❑ BUSINESS/FACILIIYISREIPROJECT NAME w \ \sem -}l yv r C`l ip�_Q C SITE ADDRESS/PROJECT LOCATION l_` +0.• - --yY�T \ SUITE 0 BUSINESS PHONE I S S o i N�.�•�s r`� Y� CITY STATE LP CA YZ BOARD OF SUPERVISOR DISTRICT I LOCATION CODE I KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADORE sB ATTENTION:ORCARE OF(OPTLONAL) MAILING ADDRESS CITY STATE LP SIC CODEISIS COMMENT: \-I -I ^ `io _O S S L ��>rLtia�. U oLf-� THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME \ ` .../ ATTENTION:OR CARE OF(QPTIOIVAL) MAILING ADDRESS PHONE C-C-'y v �� `fib CITY STATE zip 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,Authorized Agent,or Responsible Parry and 1 ackw%ledge that all PEAwr FEEv, PENAL77E5,ENFORCEttENT CHARGES and/or HOL'RLYCHAROES eSsociatedµith this project Will be billed to me at the address identified above as the ACC0UA1TADDRFSS for this site. I also certify that all information provided on this application is true and correct and that all regulated activitiesµill 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,AudiorizedAgent,or Responsible Parte for the project located above under facility/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL Hi_ALTH DFPARTMFNT as.coon as it is available and at the same time it is provided to me or my representative, APPLICANT NAYS(PLEASE PRINT) -� Q L 2 d D SIGNATURE TITLE —"P v VVV r� TAX ID Qr L4 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT X CHECK# RECEIVED BY WORK PLAN PE FEE:$