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San Juin County Environmental Health *artment <br /> DATE 1 ,f a3/fit v MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 11 "1 SITE MITIGATION & LOP <br /> sHADEDAREAe FOREHOUSEONLY OWNER IDs CASE# UNIT IV <br /> OWNER FILE:COMPLE7F 7NEFOLLOW/NG PROPERTY OWNER INFoRMATt w CHEcKIF OWNER CuRRENnyczvmLEwm EHD � <br /> PROPERTYOWNERNAME I Knoto L <br /> First MI Last PHONENUMBER <br /> Busimm NAME ^ CSte�k-(•�,,, E-MAILADDREss <br /> Owner Home Address lT <br /> CRyG, STATE ZIP <br /> G C <br /> Owner Mailing Address <br /> Mailing Address City state ZiR�Z <br /> e 4�`v <br /> 11IDo l C O <br /> CORPORATION❑ INDIVIDUAL[] PARTNERSHIP FED AGENCY OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INvESTIGATION LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWOCB_DTSC_EPA_ <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> BUMNEBslFACItfrYISOENAME v � <br /> SREADDREss t�j�II�1 t� � ._ Sur-E# BUSINNEESS�PPHHONNEE <br /> Care � <br /> C `l tb �- Zlr <br /> BOARD OF SUPERVISOR Durnacc LOCATON CODE KEPI KEY2 <br /> Math Address ifD/FFERENTfran FscOHyAddress <br /> Attention:orCare O/ pfkvra/J <br /> 80Icen <br /> Mailing Address City /Y/t STATE P <br /> SIC CODE AP COMMFM: `/'b Lab <br /> IL- <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of(ophorra/J <br /> Mailing Address PHONE <br /> CRY STATE ZIP <br /> ACCgyYrEt OHES4 for fees and charges OWNER FACILITY/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 P£AMrr FEES, <br /> PEKALTits,EAzvR[EmEMCHARGes and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOOATADDRESS for this site. I also certify,that <br /> 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 CODMY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time his <br /> provided to me or my representative. n <br /> APPLICANT NAME(PLEASE PRINT) Vk4!4r- SroNATURE <br /> TITLE TAx ID# <br /> Approved By Data Ane gofORice Proceealne Compbted By <br /> Data <br /> BY <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECENED :WDRK PLAN PEC <br /> FEE:$ <br />