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San Jr ryliin County Environmental Health Do—irtment <br /> GATE MA: ER FILE RECORD INFORMATION "Mir._'' GREEN FORM <br /> L�i �- SITE MITIGATION & LOP <br /> SHADED AREAS FON.ftM'b ��•.�aE ONLY OWNER ID# CASEA 071 <br /> UNIT IV <br /> OWNER FILE-.COMPLETE THE FOLLOW/NG PROPERTY OWNER/NFORMA77oAf: CHEomir OWNER CURRENTL YON FILE W/TH EHD <br /> PROPERTY OWNER NAMEDuna -T �2�1` <br /> First IMI Last PHONE)NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Addnsss <br /> _ °JS�� MoYrin�alclQ �Y1U-P <br /> sky STATE 7jP <br /> Owner Mailing Address <br /> _ 1 <br /> Mailing Address city stateCk-Af>n P , 9sa� <br /> CORPORATION❑ IN MMAAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SIT!MM"TION ENVIRON AL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FAaurY 1D# INV# ACCOUNT ID PR RO* ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC EPA_ <br /> -/,2.5' 9 <br /> FACILITY FILE COMPLETE7NEFOLLOIMNG BUSINESS/FACILITY/SITE/NFORMA77ow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Q <br /> IS this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ] <br /> Bus1NESB/FAcwT`(/SITE NAME <br /> $ITEADDRess SUITE* BUSINESS PHONE <br /> CITY , STATE ZIP c <br /> 5 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY') KEY2 <br /> Mailing Address NO/FFERENrfrom Fact/KyAoldws Attention:orCare Of(op&via/J <br /> Mailing Address City STATE Zip <br /> SIC CODE APN# COMMENT: <br /> ! G3 - l3o -01 <br /> -11 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attentlon:orCare Of(opfiona/) <br /> Mailing Address PHONE <br /> CITY STATE LP <br /> 7 <br /> AawyNTAwmw for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT'FEES, <br /> PENu zm] ENFORCEMENT CHARGES and/or HOURLYCHARGE.P associated with this operation will be billed to me at the address identified above as the ACC'OUNTADDRESS for this site. 1 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 located at a above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE R ENT-Ajson <br /> aa"ilable and at the same time it is <br /> provided to me or my representative. _ <br /> APPLICANT NAME(PLEASE PRINT) 6, <br /> H L-+f SIGNATURE <br /> lA �1 <br /> TITLE-�,,<' _ � 1'i1f/fl (�)��YIUIY[Y'�^Ct'�"Ll�, TAX 1 D <br /> Approved By - - - I DW Accounting Office Proceasing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPERECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />