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San Joanuin County Environmental Health apartment DATE ,n Mt._ I*ER FILE RECORD INFORMATION«ARff GREEN FORM / SITE MITIGATION & LOP SHADED AREAS FOR EHO USE ONLY OWNER ID# I �_ CASE# '5200 �3--1-7(1,_, UNIT IV OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMATION.' CHECK/F OWNER CURREN7LYONF/LEN7TH EHD ❑ PROPERTY OWNER NAME on ( ) First M1 Last PHONE NUMBER BUSINESS NAME EMAIL ADDRESS Owner Home Address City STATE LP Owner Mailing Address Mailing Address City State Zip CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ SITE MITIGATION ENVIRONMENTAL ASSESSMENT,VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION_LOP FACILITY ID# INV# ACCOUNT ID PR O# LASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB_DTSC EPAV F7 3- -7S3 53L,� mac; -_ FACILITY FILE COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES i1`1 No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ BUSINEsWFACILITY/SITE NAME SITEADDRESS SUITE# BUSINESS PHONE CITY � ATE ZAP BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS KEY-2 Mailing Address/f DIFFERENT from FacllllyAddrew Attention:orCare Of(opgonal) r.P �i. ►. t I; barn � N a� � - I��`TCt�s Mailing Address City' J STATE LP //ll /" ' , ' (� V SIC CODE APN# COMMENT: THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. B sl NAME Attention:orCare Of(optional) amai4izl.. Irv-, ling Address PHq -) 3� ' I D �T TE `Z11Pl1Lg5QQ s for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, PEivALT7Es,ENFORCEMENT CHARGEs and/or HouRLYCHARcEs associated with this operation will be billed to me at the address identified above as the ACCOUNT ADDRFSS for this site. I also certify that aB information provided on this application is true and correct;and that all regulated activities wW be performed in accordance with aH 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 DEPART NT as so 'as i is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) R f4-\P r.{ SIGNATURE TITLE �)Y p TAX ID# SI�P��11 Approved By Date Accounting Office Processing Completed By Date SITE MITIGAT ON AMOUNT PAI DAT/EJ.OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# REC WE BY WORK PLAN PE FEE: °� �