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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAS FOR EHD USE ONLY OWNER ID* O Li DOC CASE* S / 7 I ` UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: J CHECK IF OWNER/S CURRENTL Y ON FILE WITH EH PROPERTY OWNER NAME \ > FIRST MI UST `PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS SCLn O L.CI%I 60 u /��6IJ� W orgy (Lo��s OWNER HOME ADDRESS CITY Sfaak1-'v STATE zlPc/JZds—LDZ3 OWNER MAILING ADDRESS MAILING ADDRESS CITY `J STATE ZIP ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOL TARY CLEANUP X WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNTID PR * ASSIGNED EMPLOYEE LEAD AGENCY:EHD--Y--RWQCB_OTSC_EPA JvI�N� FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES NO ❑ IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ NO BUSINESSIFACILITYISITE/PROJECT NAME \. / I�aN^ S �+ 5p"f I• SITE ADDRESS/PROJECT LOCATION / SUITE# BUSINESS PHONE CITY / /-STATE ZIP E-5!C0.lW1 CtqTA BOARD OF SUPERVISOR DISTRICT 014 1 LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORC E OF(OPTIONAL 112-c(c-( Pl fl >r-S W {X MAILING ADDRESS CITY C-76 I„J {� i�J., TATE ZIP C� 1� r-} �j 5Cc—10 SIC CODE APN# COMMENT: d� THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME /111�v FN ul"(_"C /G I ^C` ATTENTION:ORCARE OF(OPT/ONAL) MAILINGADDRESS 112-"9 1 �f"` 9 P��JIjS� ��y L PHONE (-V` P51 _0 '- CIrY Id ��u-c-f� C n E ZIP 9S'(.0-7 0 ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Part}and I acknowledge that all PEtwtT FEES, PENALT/HS,E.VFORcFAt&5T C!/ARGE4 and/or HOURLYCKaRGES associated with this project will be billed to me at the address identified above as the ACConTADDRESS for this site. I also certify that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SANJOAQUIN COUNTY ORDINANCE CODES and/or ST.VYDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Paro,for the project located above under facility/site address,I hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL ESLnt DEP NIF-N rr is av ' ble and at the same time it is provided to me or my representative. r APPLICANT NAME(PLEASE PRINT) /�`I C 11 C,-C, Gtr �G✓� GFLC�f:.� SIGNATURE / TITLE /�rp/CGT TAxID* 0,"IJ(.o--7 APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY ATE SITE MITIOATION AMOUNT PA DA�T/E OF PAYMENT PAYMENT TYPES RECEIPT# CHECK# RECEIVED BYt� WO$K QLANPE PE FEE: 3�S �� l'� —I� C� 14-IrdK