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SAN JUIN COUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> cc » GREEN FORM <br /> DATE Iolc MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> T--SHADED AREAS FOR EHL USE ONLY OWNER ID# <br /> CASE# UNIT IV <br /> CHECK IF OWNER ISCURRENTLYONF/LE WITH EHD <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: �� <br /> FOWNERMAILINoADDREISIS <br /> AME <br /> cv,a�c1 �a (09) -foo L <br /> FIRST MI LAST PHONE NUMBER , <br /> E-MAIL ADDRESS <br /> RESS O,m L� <br /> 1�.//�,•"cU CJ j<►'`ji 1 l.. �C.i STATE i-bp <br /> CAfA <br /> L)C DDRESS <br /> STATE ZIP <br /> [MAILING ADDRESS CITY �{ <br /> ❑CORPORATION [:1 INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY <br /> {C]RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#/ROA ASSIGNED EMPLOYEE LEAD AGENCY:EHD._RWQCB—OTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> YES No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,rBUUT A NEW SCOPE OF WORK? <br /> BUSINESSIFACIUTY/SITE/PROJECT NAME Cl- 1\rA <br /> �/lCs SUITE BUSINESS PHONE <br /> SITE ADDRESS I PROJECT LOCATION 00 <br /> n t1 /`l,/� � STATE� ZIP <br /> CITY <br /> 'oCk%F-V I") <br /> BOARD OF SUPER1,11I8OR DISTRICT <br /> LOCATION CODE KEY1 KEY2 <br /> ATTENTION:ORCARE OF(OP77OA94L) <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS <br /> STATE ZIP <br /> MAILING ADDRESS CITY <br /> [SIC CODE <br /> A�* � COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER ORRESPONSIBLE <br /> ARESPPONSIBLEE OF PPAn�IJENTIFIED ABOVE. <br /> BUSINESS NAME <br /> PHONE <br /> MAILING ADDRESS <br /> STATE ZIP <br /> CITY <br /> FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responshh/e Party and I acknowledge that all PERMIT FEES, <br /> ite. I also certify that all <br /> C(/ARLES associated with project will be billed p forme at the adress identified above as the med in accordance with all applicable S JU TADDRESS for O QUIN COUNTY <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY ORDINANCE CODES and/or <br /> information provided on this application is true and correct;and that all regulated activities will be pert <br /> r,Au <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operatotrorized 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 TH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. `+ <br /> $IGNATUR Zft, <br /> APPLICANT NAME(PLEASE PRINT) V <br /> .- <br /> TAX ID# <br /> TITLE <br /> APPROVED By DATE <br /> ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> ECEIVED BY <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RWORK PLAN PE <br /> FEE: <br />