Laserfiche WebLink
San Aquin County Environmental Health9partment <br /> DATE /(�l3 I/ I MASTER FILE RECORD INFORMATION cdMFRrr GREEN FORM <br /> / Z SITE MITIGATION & LOP <br /> B O END O OWNER ION CASE# 4`s' (d S UNIT IV <br /> OWNER FILE:COMPLETE TNEFCSOLLOWNG PROPERTY OWNER WFORMA TION.' CHECHIF OWNER CUMRENRYONF/LEWITH EHD� <br /> PROPERTY OWNER NAME \� C& �Coc M <br /> First MI Last PHONE NuNwER <br /> BUSINESS NAME E-IAILADORESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address Ctiy State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_NW PIPELINE INVESTIGATION LOP <br /> FACILITY I # INV# ACCOUNT ID PR E4 RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHC RWQCB j1( DTSC_EPA <br /> ?3(o dANVoy - <br /> FACILITYFILE COMPLETE THEFOLLOWMIG BUSINESS/FACILITY/SITEINFORMATION: <br /> Is this a NEW Business LOCATION not preViously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No C& <br /> Is this an E%ISTING Business LOCATION but a NEW`TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESWFACILITY/SITE NAME I.\�n (kn''ep C t1vr ll�c�nnlecci-Le� )j\ <br /> la iDP1 TC'Ih$ <br /> $ITEADORE3S M1 /I/�S� `��en��m1N �01� �� / �1'. 1 u �'^ $UnE# BUSINESS PHONE <br /> Cm `/ Sto c\bn .1 fV" �,'(�_,J'C'D rX <br /> STATE 21P <br /> BOARD OFSUPERVISORDISTRIOT LOCATION CODE I KEY1 KEy2 <br /> Mailing Address MO/FFERENT#PnnFec/N/yAddYMsa / �1� II Attention:wCare Of(opfbne/J <br /> 7o &Nell /U:\ar\c1 T�Ins�ee (� 205 AI?e COc1S\4�T(A�1'tS enc. <br /> Mailing Address City '30A3 / n1STATE ZIP <br /> JlL/ <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner OrFaCility Operator identifled above. <br /> BUSINEs3N11ME RGAI\C-� Attention:o Cara Of(optlpuQ <br /> Mailing Address PHONE <br /> a.DDU oi1,�e�� S�-, �+�' door 51c-L55a- LI5a6 <br /> CITY E V 1` STATE c'1 ZIP <br /> A-CCOUVEAnuffim for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the(hurter,Operator,or Authorizer/Agent of this Business,and I acknowledge That all PERMIT FEES, <br /> PENALTIES,ENFORCEM£NTCHARGES and/or HOURLY CHARGES associated with this operation will be billedto me at the address identified above as the ACCOUNTAHUResS far this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities win be performed in accordance with 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,I hereby authorize the release of <br /> any and all main and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT TM NT as soon as i�av;BbIe and at the same fine it is <br /> provided to me or my representative. <br /> APPLICANTNAME(PLEASEPRINT) <br /> r�D t,1'1 O MNSIC � SIONATIRE <br /> TITLE \Qy IS� TAX ID III <br /> A roved By Data ` Accoun#n 1 Office Proc sseln i Completed B Data <br /> $ITEMITIGATIpN AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$/(V/Jy <br />