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San Jelin County Environmental Health partment <br /> DATE MASTER FILE RECORD INFORMATION "IRR" GREEN FORM <br /> SITE MITIGATION a LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNERID# OI.0000SD 07 CASE# UNIT IV <br /> OWNER FILE-COMPLETE THEFOLLOW/NG PROPERTY OWNER lwojy}M—AT/ON: CHECKIF OWNER CURRENrcyorvFILEWirif EHD <br /> PROPERTY OWNER NAME �/1Aor(.L G //((r(�I >�r/ �/ (aaf) tor-07 F/ <br /> Firstf MI Lest PHONE NUMBER <br /> BUSINESS NAME t /'/ ��ke / "X I <br /> Owner Home Address <br /> city STAyE�l zip <br /> /� <br /> Owner Mai)"6517 as <br /> Mailing Address City �(i l�rY Ste zip '�rS ;Ivr— <br /> CORPORATION62— INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION—ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP X WATER QUALITY—HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNTID PR#IRO#�4-11VQ Ass IGNEDEMPLOYEE LEAD AGENCY:EHDRWOCB_DTSC_EPA_ <br /> 2 Woµo251 53811b pJVI Nenkkrs6NI <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY I SITE/NFORMAT/OM <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Na.El' <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> BUSINESSII( SITE NA <br /> SITE ADDRESS ! r /I„ _ (`L /� SURE# BU;Ess PH /' <br /> // <br /> CITY ! l/•✓ //LIY/''r✓ C1d7Y lf/✓ sZZ zC/P�/�. V's � <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEYt KEY2 ENT <br /> Mailing Address ifOIFFERENTfronsFacility Address Attention:orCara Of(optional <br /> DECQ <br /> 8 2013— <br /> Mailing Address City STATESAN z�IbAOU1N COU <br /> SICCODE APN# COMMENT: HEALTHOEPggTMENT <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiriedabove. <br /> BUSINESS NAME //,/% �� Attention:0 gar Of (O t' 1), <br /> (fi ./ Gt�h2 a� �/.J.�.tnd.-u <br /> Mailing Addre7ff3 ` �- ./ (�„lN� P_�H�ON � <br /> �� / 6n,r0zip <br /> / <br /> CITY Jkp& /g <br /> ' /N s6/I" r.+t.—TE `7?N I <br /> AccouNTADORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Audroriced Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALTms,ENF'ORcEm&w CHARGES and/or HOURLY CHARGEs associated with this operation will be billed to me at the address identified above as the Acme ADDRESS for this site. I also certify that all <br /> information provided on this application Is One and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOADUIN 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,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIIN COUNTY ENVIRONMENTAL HEALTH 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 PRINT) f�9�, D-hme rs j�!/ SIGNATURE (/ �/IYL.i-✓ <br /> G/ TAX ID# <br /> TITLE J 9y-/C/9G'7y <br /> Approved By Date Accounting Office Processing Completed By Date I y ql(3 <br /> SITEM@ITIG�ATTIONf;M;7UNTPAID, DATE FP MENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ 1 1� �� � Y (/ ZV/1f/ 3 <br />