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San Joaq >n County Environmental Health De artment <br /> oarE C MASW FILE RECORD IN96FORMATION MGREED FORM <br /> SITE MITIGATION & LOP <br /> ?l UNIT I V <br /> SHADED AREAS FOR EHD USE 817,ONLY OWNER IDN CASE# <br /> OWNER FILE:COMPLETErHEFOLLOWINGPROPERTY OWNER INFORMATION. CNECKIFOWNERCuRelxrLroxFrirwrrxEHD0 <br /> PROPERTY OWNER NAME ( ) <br /> First M! Last PHONE NUMBER ( '4 S79 <br /> E-MAIL ADDRESS <br /> BUSINESS NAME f <br /> Owner Home Address <br /> City STATE ZIP <br /> 3 <br /> Owner Mailing Address <br /> Meiling Address City State ZIP <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIRONMENTAL AssmmrxT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID P RO# ASSIGNED EMPLOYEE LEA�D!AGENCY:EHDRWf,}CB OT$C_EPA..._._ <br /> FACILITY FILE COMPLETETHEFOLLOWNG BUSINESS I FACILITY I 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 <br /> BUSINE351FACILITYISITEtiAME <br /> R �rreeNwti er <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> s+ <br /> CITY S `^� `STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT '(v LOCATION CODE KEY1 KEY2 I <br /> Mailing Address 1fD1FFERENTfromFacNltyAddrsw Attention:or-Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> --------------- <br /> SIC CODE APN N 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 (optianal) <br /> PHONE <br /> Mailing Address <br /> Z-Z MercUr UUa Sv ti s5� —70 7 5Z�— fvtD <br /> STATE ZIP <br /> CITY CA 4 S�07 <br /> for fees and charges OWNER FACILITYIBUSINESS 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 PERMIT FS&i', <br /> PEN vT'1Es ENFORCEAiEm7 CHARGES and/or HOURLYCHARGF-v associated with this operation will be billed to me at the address identified above as the ACCouvTAnoxecs for this site. !also certify that <br /> all 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 Iocated at t abo acility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEI'A 4 NT s soon s it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLt�EASE PRINT)1 0O V , <br /> b\&Uq SIGNATURE C <br /> TITLES�UA TAX ID# <br /> Caen o��� <br /> rApproved By Date Accounting Office Proce;�� <br /> ted By Date <br /> 517E MITIGATION AMOUNT PAID�/j DATE OF PAY ENT PAYMENT TYPE RECCHEE/CCK#�/j(](spy REGEIIVED BY WORRK�}PLAN7PE <br /> FEE: ``G l <br /> all <br /> f 1 f <br />