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r� San Jt. ,uin County Environmental Health`�f `Ata inn# (DATE j MASTER FILE RECORD INFORMATION"MF » GREEN FORM R�EB 2 29"9 MITIGATION&LOP SHA DEO AREAS Fog EHD usE ONLY OWNER ID# CASE# ��>> UNIT IV NUS SOWA�EIIln'LFiEZIri OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMArtow CHE, 'WY,0AfaewmH EHD PROPERTY OWNER NAME E ( ) First MI Last PHONE NumeeR BUSINESS NAME E-MAIL ADDRESS Owner Home Address city STATE zip Owner MaIWV Address Malting Address City State zip d fiv y� 614 5 5 3 S-ia CORPORATION❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SITE Mrn"TINN_ENVIRONMENTAL A ses"ENT VOLUNTARY CLEANUP WATER QUALITY HW Pimm INVESTIGATION_LOP_ FACILITY ID# INV# AccouNT ID PR#f RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA � as FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BusmwssIFACILITY/SRE NAME SITE A DRESS SUITE# BUSINESS PHONE CITY STATE zip BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 Mailing Address KDIFFERENTfrom FacilflyAddress Attention:orCare Of(optIbnal) Mailing Address City STATE zip SIC CODE APN# CoMMENr: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identirled above. Busi Ess NAME Attention:orCare Of(opbbrol) C A- Mailing Address PHONE Cm STATE zIP /. 95-4 3 0 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, PENALT/Es,ENFoRCEmENTCHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCOUNTADDRESS 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 COUNTY Ordinance Codes and/or 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 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 provided to me or my representative. APPLICANT NAME(PLEASE PRINT) rem\ I SIGNATURE �— TITLE TAX ID# `jc,ak ^n C- S� - 033 e t Date Accounting ORice Processing Completed B Date GATON AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BV WORK PLAN PE