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San Jt uin County Environmental Health C irtment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> A SITE MITIGATION& LOP <br /> BHADED AREAS FOR EHDU EONLV �•`�,r_`���/3 U�l�T I V <br /> OWNER ID# CASE#S2UU 6 S'j (y NIT <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY lwoRmA.nloN; CHECKIF OWNER CURRENTLYONPILEWIrH EHD <br /> PROPERTY OWNER NAME 1 zy / (&Sq 5,1 G <br /> / n��D <br /> First J ,/ Ml Last PHONE NUMBER[ <br /> BUSINESS NAME O f` f Q n E-MAILADDRESS n'l <br /> Owner Home Address <br /> �- <br /> city STATE ZIP <br /> C� <br /> "If 65"40 <br /> Owner Mailing Address <br /> Q o <br /> Mailing Address City State Zi <br /> As A.�D V't- P <br /> ,CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP WATER QUALITY__HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID# IN ACCOUNT ID PR#/RO# ASSIONEDEMPLOYEE' LEAD AGENCY EHD -.RWQCB�DTSC'_EPA_ <br /> ��002 PQo53y��5 1G��( <br /> FACILITY FILE: COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an EXISTING PrOjeCt LOCATION but <br /> --a NEW SCOPE OF WORK? YES ® NO ❑ <br /> BUSINESS/FACILITY/SITEIPROJECT NAME <br /> SITE ADDRESS 1 PROJECT LOCATION SUITE# BUSINESS PHONE <br /> 1021 :FrVA-tA e- zoo $32-- 5W6 <br /> CITY STATE ZIP <br /> on G4 <br /> BOARD OF SUPERVISOR DISTRICT �. _ LOCATION CODE Q KE17 KEY2 . <br /> Mailing Address ifOIFFERENTfrolnFacilityAddress Attention:orCare Of(optional) <br /> 1 0b Su`,+e 2_ <br /> Mailing Address City ^�Iv S STA E ZIP <br /> C <br /> SIC CODE APN# 7COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME Att ntion:orCareOf (optlona/ <br /> corKd'fa &- w-a AsSOGiafe a!A- 'rildlol <br /> Mailing Address PHONE <br /> orr;S s+ St;.fit [42oLl 2.0 -332,S <br /> CITY STATE ZIP <br /> �m-ez v�(f- 09 <br /> AC,couNTAnnaFco for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> HILLINC AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENTCH4RGEs and/or HOURLY CHARGES associated with this project will be billed tome at the address identified above as the ACCoUNTAnnRE.vY 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,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my representative. <br /> . <br /> APPLICANT NAME(PLEASE PRINT) Tar a L� {� I ffi n et^ SIGNATURE <br /> U1,Ar TAX ID# �F t/s+-Q <br /> TITLE S A4— 6 10 i S4- A liT17 M 11 AlZ45"8124 <br /> Approved By Date Accountin Office Processing Com leted By Zoe, I Date b It 2/ <br /> SITE MITIGATION I AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT 0 CHECK# RECEIVED BY WOR/�KQPIAN PE <br /> FEE: /� I�QU.. .._. <br />