BILLING - Laserfiche WebLink

Home Browse Search

SAN JUAQUIN COUNTY ENVIRONMENTAL HEALTH uEPARTMENT DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION &LOP SHADED AREAS FOR EHD USE ONLY7 OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IFOWNERISCURRENTLYONFUEwiTy EHD PROPERTY OWNER NAME ( 1 FIRST MI LAST \PHONE NUMBER BUSINESS NAME ` E-MAIL ADDRESS Sa-n o Lct� �uw> PKb/fc bi oeg5 acc'dg ) OWNER HOME ADDRESS f S,b (avA rut*' CITY STATE ZIP StackFz- � el9 .j5,6S--6-2.3 OWNER MAILING ADDRESS MAILING ADDRESS CRY STATE ZIP ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP x WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOLL AGENCY:EHD RWQCB_DTSC—EPA— 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? r YES ❑ No BUSINESSIFACILITY/SITE/PROJECT NAME SITE ADDRESS I PROJECT LOCATION Z'L-7 SCSUITE# BUSINESS PHONE C-( E. M--203— R-0--d CITY / STATE ZIP FsC0.lO� C I7 BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORC E OF OPTIONAL) / I I Z`-(`- P`1 'r-5 W {x Fn,,,,k f r"C. MAILING ADDRESS CITY C-76 I„J (Z tt TAE ZIP S� SIC CODE �= APN I#� COMMENT: / THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAMEt_K Fh Ut'Vt7i-Cc4 1+1.C, ATTENTION:ORCARE OF (OPTIONAL) MAILINGADDRESS f Py rl' .s W PHONE CITY &mr �f STATE ZIP^\ (x- ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING BILLING.AND COMPLIANCE ACFN'Ow'LEDGMENT: 1,the undersigned:Applicant,certify that I am the Owner,Operator_luthorited:lgent,or Responsible Pari),and I acl:noisiedge that all P£a.IfITFEE.S, PE.AAI]%ES,E.A'FORL''EvEAT CILIRGEI'and/or/10t M.YCIGIR6EY associated with this project gill be billed to me at the address identified above as the A(YY/C'ATADI)RESS for this site. 1 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 SAN JOAQUIN COUNT}-ORDINANCE CODES and/or STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned(hvner,Operator,Authorized Agent,or Responsible Para,for the project located above under facility/site address,1 hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JO.AQUIN COCNTIEwIRONAtEN r.AL EALTII DEP �NIENT as coon tis ac .ble and at the same time it is provided tome or my representative. / /j APPLICANT NAME(PLEASE PRINT) ��I c tA C,.P— ( U C"n de—'x E-'dC q'\ SIGNATURE TITLE ((((( t-o/CGT TAxID# /„C/`Q^� -t �-7 Co APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY `.cam D J DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE FEE: