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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATEj Z� I J MASTER FILE RECORD INFORMATION "MFR" GREEN FORM `cam 111 I SITE MITIGATION&LOP SHADED AREAS FOR END USE ONLY OWNER ID# TCASE 1 UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECKIFOWNER/s CURRENrLyoNFILEwirH EHD PROPERTY OWNER NAME FIRST M/ LAST PHONE NUMBER E-MAILADDRESS BUSINESS NAME ^ LI r-jc.01'1 ��o e��r� 3 L� U� S 0 OWNER HOME ADDRESS 3Q x I Cm � rf 1 STATE ZIP SJl�vtt OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE —Fill CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_ HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# AccouNr ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ BUSINESS/FAC[LIT//SITEIPROJECT NAME SITE ADDRESS/PROJECT LOCATION L� SUITE# BUSINESS PHONE CITY CSTATE ZIP BOARD OF SUPERVISOR DISTRICT 7 LOCATION CODE �� / KEY'I KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE ZIP SIC CODE APN# �! COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME1 _ I ATTENTION:ORCARE OF (OPTIONAL) e-Ali d d,J F tit C �-I J ��}rv�enc C o t I�� : t u�J L (a c _ We J lGto MAILING ADDRESS I L / PHO E / l c f O r a O 17 a✓ a Jl l 6 CITY STATE ZIP c Lw Cn r o CL,A- J6 0 ACCOUNTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLINc4e BILLING AND CONIPI.IAN('E ACKNOw LF I)CNiFNT: I,the undersigned Applicant,certify that 1 am the(Dvner,Opernrnr,Awhorced Agent or Revponvible Part,and I acknowledge that all PERAfn FEFS, PFAA1,7IES,ENFORCEVENI Cl/ARGE.0 and/or 11011RIA CINRGES associated with this project will be billed to me at the address identified above as the AcCOLvi ADORESB for this site. I also certifv[fiat all information provided on this application is true and correct;and that all regulated activities%sill be performed in accordance with all applicable S.AN JO.AQUIN COUNlY ORDIN'ANC'E,CODES and/or STANDARDS anti STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Onwer,Operator,Authorized agent,or Rehpunsible Part),for the project located above under facility/site address, hereby authorize the release of any and all results,reports,and other environmental assessment information to SAV JOAQUIN COUNTY ENVIRON?tFNT.AL HEALTH DEPARTMENT as soon as it is available and at the same time itis provided[o me or m rep resen[afve. r r� w APPLICANT NAME(PLEASE PRINT) �✓\ ` p� 'qJ SIGNATURE TITLE TAX ID# APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE SITE MITI?CATION AMOUNT PAID DATE OF PAYMENT PA�I�;Y RECEIPT# CHECK# RECEIVED BY WORK PL<A'NIPE FEE: J 7.� �� _�,/y C - �3Z 2cZ ��CIaIJ 2