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San J 00 <br /> in unty Environmental Health Dortm t <br /> � <br /> « » GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR ad// SITE MITIGATION& LOP <br /> S' 5RSHADED AREAS FOR EHD USE ONLY OWNER ID# I CASE# �O UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NGPROPERTYOWNER AfFORMATION: CmcK#:OWNER CuRieEmnyowniewrrHEHD <br /> PROPERTY OWNER NAME / tI (� �� O(O — O <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME Cb"" E-MAIL ADDRESS <br /> Owner Home Address <br /> /03V Ci &- <br /> C* <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State LP <br /> CORPORATION❑ INDIVIDUAX PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> [�������������EfDRWQCBLOYEE LEAD AGENCY:EHD RWQCB_OTSC EPA <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON: <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No,-E�T' <br /> Is this an ExISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ ND,.e <br /> BUSINESS/FACILITYISITE NAME t::�! Y^ <br /> SITE ADDRESS (w r SUITE# BUSINESS PHONE <br /> CITY �?� STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 S <br /> Mailing Address KDIFFERENT from Facility Address Attention:ot-Care Of(option/) <br /> Mailing Address City STATE Zip <br /> $IC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if BI "ng Party is differept from Property Owner orFacility Opdrator identified above. <br /> BUSINESS NAME Attention: Of(opbonal) <br /> Mailing Address �Z I PHONE <br /> CITY A, STATE ZIP <br /> ACCOUNTAD09M for fees and charges OWNS FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the ursigned Applicant,certify t 1 am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT Fees•, <br /> PENALTIES,ENFoRcEmENTCHaRGEv and/or HIIURLYCHAR associated with this operation will be billed to me at the address identified above as the ACCOI/NTADDRESS for this site. I 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 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 <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) Si e�e L (ek^ W SIGNATURE <br /> TAX 10# <br /> TITLE <br /> GOtiI Sy�7ri u / <br /> Approved By Date Accounting Office Prmessing Completed By _ Date <br /> $ITE MITIGATION AMOUNT PAID DATE OF PAYM-E�NTT� PAYMENTTYPE RECEIPT# CHECK# RECEIVEDBY <br /> WORK <br /> PLAN PE <br /> FEE:$ l � J l i'IV �.IL— ` S*71 l `i \ , /�� <br />