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San Jt jin County Environmental Health ► artment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> �.^ I' SITE MITIGATION&LOP <br /> SHAOEDAREAS FOR EHDUaE0ti1,Y OWNERID# CASE# �.0 DD�p4iy-� UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER INFORMATION., <br /> CHLEcKIFOWNER CURRENTLYONFiLEwirHEHD <br /> PROPERTY OWNER NAME <br /> First M/ Last PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> ------__-_-- PO (Sox 212-t <br /> City STATE ZIP <br /> ( ,ll Vc,lle C�� 9y`1�; z <br /> Owner Mailing Address <br /> P0 Nwx ZiZ <br /> Mailing Address City State Zip <br /> M' I UGII� <br /> It 4`r u-2- <br /> CORPORATION <br /> CORPORATION❑ INDIVIDUAL' PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> t <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP (ATER UALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# INv# ACCOUtiT ID PR RO• 'sur" o"ir '2 EHDI21iCB_DTSC'- E >k" <br /> 3Bfl9 l3 °; r fi<00 <br /> FACILITY FILE COMPLETE THE FOLLOW/NG BUSINESS/FACILITY I SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No El <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 1] <br /> BUSINEss/FACILITYISrTE NAME,— <br /> (' �- <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> L L)Ll o E. ,Mctit,\ S+. .v A <br /> CITY STATE ZIP <br /> g52�S— <br /> [BOARD OF 8UPERWSOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifD/FFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE <br /> Jff]: ry a'/7,5-D:3jCOMMENT: <br /> THIRD PARTY BILLING INFO: Complete if BillingPartyis different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME 1 nZ '!e I I\ Attention:orCare Of (optional) AVL `I JS/fir <br /> Mailing Address Y^ l P ONE <br /> Z35 C t Gu rn� Sul `�' �-]o: 2 S - 10 I D <br /> CRY STATE LP <br /> Sc" ' �p�a C R 45407 <br /> AgawxTAOaaw for fees and charges OWNER FACILffY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACIMOWLEDGMENT: 1,the Undersigned Applicant,certify that I am the Owner,Operator,or AmborW Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALrms,ENFORCEMENT CHARrw and/or HOURLYCNARGFs associated with this operation will be billed to me at the address Identified above as the ACCDUNTADDRESS for this site. I also certify that all <br /> Information provided on this application Is true and correct;and that all regulated activities will be performed In accordance with all ap licabl -SWJOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the proplocated at the a fa <br /> erty cility/site add ess,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM NT ason/as it' available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) 3-101 �On U A USIGNATURE t � <br /> TITLE <br /> 1 <br /> Approved By Date Accounting Office Processing Completed By Date / 11112— <br /> TION <br /> ( 1ZTION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PES <br /> FEE: <br /> _ 1 agoi <br />