Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> DATE '�I I' MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> �r/� �S SITE MITIGATION & LOP <br /> SHADED M SFOREHOUSEONLY OWNER ID# CASE#SLOto32—'? UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFORMA7/770�N.'I`�/ CNEcx/F OWNER CURREEA, YoNRLErarm EHHD � <br /> PROPERTY OWNER NAME n/I 'LA D , A 40 / �� .-. 77640 <br /> First Ml Last PHONENUMSER <br /> BUSINESS NAME �. I./( IT rAc. E-RAILADDRESS <br /> Owner Home Address <br /> P. O. 13 O <br /> CRY STATE LP <br /> s fA t � <br /> P. <br /> Owner Mailing Addr-- CA C <br /> Qa I&S PO <br /> Melling Address City I ( CIA <br /> State CA Zip S 3 <br /> CORPORATION INDIVIDUALI❑l PARTNERSHIP El FED AGENCY El OMER❑ <br /> SITE MITIGATION)&,ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# AGCOUNTID PRI#IRO# ASSIGNED EMP OYEE LEAD AGENCY:EH D RWQCB_DTSC_EPA <br /> /kKtth31-11 55b 0 <br /> FACILITYFILE COMPLETE THEFOLLOWINGBUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No [� <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No <br /> SUSINESs/FACILTTY'/SITENANE <br /> SREADDRESS /FIJI SURE# BUSINESS PHONE <br /> RO o;S � <br /> CITY STATE LP <br /> L.anicoq C13 2Y <br /> BOAROOFSUPERNo oft DIsmar LOCATION CODE KEPI KEY2 <br /> Meiling Address ffo1FFEREN7rrvm Fac///tyAddrass Attention:orCars Of fool/oRa9 <br /> Mailing Address City STATE LP <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME 44 Attention:WCare,Of IOpHMaf) <br /> N A GT 0 cnvt A Z,.L . <br /> Mailing Address PHONE / <br /> & 37 .59,Aw RnAo Z42 - t4 10 - /oo <br /> CITY <br /> SPATE Cad ZIP 9 S 2 S <br /> S T oc T <br /> ACOOUNTAOPRm for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undanigaed Applicant,certify that I..the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENALT/ES,ENFURC"EM'CR GES and/or HOUWYCRARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRELS for this site. 1 also certify that <br /> 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 <br /> Standards and STAIR 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. � �L <br /> APPLICANT NAME(PLEASE PRINT) /I'MOTI41 Cy£)1'41- SIGNATURE -ti,�_ <br /> TITLETAX ID# <br /> PA%3 CT MAiyA",,- Orr o3S4 (c0Io <br /> Approved BY I Data I Accounting Omce Processing Completed BY Date <br /> SITE MITIGA'�TITIP'yN,e AMOUNT <br /> IR7 DATEOFOFPAYMENT PAYMENTTTYYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEES�j 4,r� V �� <br />