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GGEwE® <br /> San Joaftruin County Environmental Health Denrr�Teot, 2012 <br /> DATE MASTER FILE RECORD INFORMATION"MFR' GREEN FORM <br /> Nov �•, 12 -- - -- _ F _AIMION& LOP <br /> RwAnon AREAS FOR EHO SE UONLY 1OWNER ID# CASE# ENvpERM1 ISERVI�� T I V <br /> 011VNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON: CHecKIF OWNER CURRENn.YON FILE wiTH EHD El <br /> PROPERTY OWNER NAME ( ) <br /> First Ml Las! PHONE NUMBER <br /> BUSINE88 NAME Pet✓o S r �I E-YAIL Ano tEss <br /> hZaI 5-�'-+ oN L L G S <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <16Z <br /> 6Z Vi 1110 t4 C7 1l cv% �G► <br /> Mailing Address City S J State c A Zip 475 <br /> 12 qtn pst Fi <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTAR LEANUP WATER QUALITY_HW PIPELINE I STIGATION_LOP <br /> FACILITY ID# INV# AccouNT ID PR IRO AS ZONED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA <br /> / _ <br /> ! 692 <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EmSTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BuslNEW1FACILrrY/SITE NAME M_K+vr`1 l t�1 -,-C -4Z <br /> SITE ADDRESS t 12,06 EoSUITE# BUSINE88 PHONE <br /> ►srt Mtil•�l, Labea <br /> CITY C-LaL/_ � STATE ZIP <br /> .J f 1� CA �szio <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY-2 <br /> Mailing Address ifD1FFERENT from Facil/tyAddress Attention:orCare Of(optional) <br /> Mailing Address City STATE zip <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Gv*J"o ATC <br /> Attention:orCare Of (optional) <br /> Mailing Address PHON <br /> lMl l� LJvtie ?J,, Ave L,4e 2Q! EZO52Z2! <br /> crrY <br /> STATE C ZIP <br /> ACCOVATADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING ANU COMPLIANCE ACtcNOWLEDCMENI 1,the undersigned Applicant,certify that 1 am the(honer,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERwy'YEEt', <br /> PEAA1-77E.S,FNF(IR[£AIEATCH4RGEs'and/or HouRt-YCHARr:6S associated with this operation will be billed to me at the address identified above as the ACCOUNTAU/1REC5 for this site. I 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 the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to S N JOAQUIN COUNTY ENVIRONMENTAL HEALTFI DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE.P ) SIGNATURE <br /> TITLE TAX ID# <br /> Approved B Data Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED By WORK PUN PE <br /> FEE: --d► ilL�1C/ 3r O <br />