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San Juin County Environmental HealtWpartment <br /> DATE MA TER FILE RECORD INFORMATION" R" GREENFORM <br /> EE-==! SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOWINGPROPERTYOWNER,/tNFORMATIOM CHEcK/F�{OWNER <br /> '�CuRHENTLYomnLEE wiTe EHD <br /> PROPERTY OWNER NAME �C� t ry Q ,S fO O <br /> f � — ZjlfZ <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME '1 ff �^ ^ '' E-MA14`�A''D / II <br /> jC TD VfN Y hs INTT•D a5 QIIC TD • Y3 <br /> Owner Home Address <br /> IZobI S4W4 jq <br /> CitySTATE ZIP���� / <br /> Mm4ecA I <br /> {/O <br /> Owner Mailing Address h,r'�i; <br /> Mailing Address City Ilr✓ IG State Zip <br /> CORPORATION INDIVIDUAL F-1 PARTNERSHIP Fen AGENCY El OTHER El <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY I lluv# ACCOUNTID PR#/RO# ATONED EMPLOYEE LEADAGENcY:EHD RWQCB DTSC_EPA <br /> FACILITY FILE COMPLETE THEFOLLOW/NGBUSINESS IFACILITY ISITE/NFORMAT/ON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No,o <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES 'S' NO ❑ <br /> BUSINEss/FACILITYISITE NAME e7 <br /> SITE ADDRESS SUITE BUSINESS PHONE <br /> CITY STATE ZIP <br /> BOARDOFSUPERVISORDISTRICT LOCATIONCODE KEYS KEY2 <br /> Mailing Address ifD1FFERENTfrom Facility Address Attention:orCare 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 orfacility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> V, U-t4TIE r5CAIJ OLD <br /> Mailing Address ^ c PHONE—ego <br /> IZ/1 ^z6 <br /> ,•I/ <br /> TATE IP l( <br /> CITY W OC L <br /> AccouvrADDRES,c for fees and charges OWNER FACILITY/BUSINESS HIRD PARTY BI LING <br /> BILLING AND COMPLIArvcE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Orvner,OperaoA or Antlenzed Agent of this Business,a at all PERnraFEEs, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACCW/NTAUDRESS 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 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,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) /Y SIGNATURE <br /> �t TITLE ; TAX ID#� n���� ��Ca <br /> bt•J N Et2 L J ` <br /> Approved By Data Accounting Once Processing Completed By Data <br /> SITE MITIG ION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ / 9 J <br />