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San A ,gyp gcWrN4f-nvironmental Health D ment <br /> DATE NiTf AMJWWD INFORMATION"MFR" GREEN FORM <br /> 'n ww A- Is C/1 SITE MITIGATION&LOP <br /> SHADES AFXM Rr USEONIy OWNERID#PLHMI 17SDIVICE —] CASE# /\ ^ IT IV <br /> OWNER FILE:COMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: V CHEca fvF NER CURRENTLYoNFILEw/TH EHD <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE/NUMBER " <br /> BUSINESS NAME E-MAIL ADDRESS <br /> SNDA ticov v - �� c <br /> Owner Home Address <br /> 0SilleA C F ( R, <br /> City STATE LP <br /> L-I v'ER- cr 9 <br /> Owner Mailing Address <br /> Mailing Address City State ZIP ��f <br /> t— <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MmoATION ENVIRONMENITAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIOA ON_LOP <br /> FACIrrfTYl�� INv# AccouNTID PR#/Not <br /> 'i'; '.'. ✓543 ..3t�:'. ti`•,. t.,-✓aL i�Fi. ,...5:f t M .• d r <br /> FACILITY FILE COMPLETE THEFOLLOw/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No'jg V' <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILiTYI$ITE NAME /N</t�S77&,Q-T'(to n <br /> LL � iE <br /> SITE ADORE33 (,let���� SUITE# BUSINESS PHONE <br /> CrTY ,Y( W V l STATE TJP <br /> ixr. vs� , <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address HDIFFERENT from Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (optional) <br /> CdNEST '/C 1? A c A _�-S �%A <br /> Mailing Address PHONE <br /> S OD 14,041-I S T v A S'/O 4e Lv ©7 o v <br /> Cm STATE ZIP <br /> - e- `1 G'/LGE C',A- (2 A 9 42150 ' <br /> Aaa2uyr9r2DRESs for fees and charges OWNER FACILfTY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLYCHARGES associated with this operation Mil be billed to me at the address Identified above as the ACCOIIATADDREB$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.vith 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 SAN JOAQUIN 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) i4,,F74-,' 11Fe- Foe (Toe SIGNATURE ----_ <br /> TITLE _ TAX IDIII <br /> Si r r =E©&a6:I5l 16 ' 2`l77 <br /> ApProwd By Data Accounting Office Processing Completed By t;d'L. Dab <br /> SITE MITIGATION AMOUNT PAID DATE OP PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN Pp; <br /> FEE:$ <br />