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T 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE j 1 I / MASTER FILE RECORD INFORMATION "MFR" GREEN FORM C� 1 111 I SITE MITIGATION& LOP SHADFn AREAS FOR EHD USE ONLY OWNER IDN CASEN UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK lFOwHERlsCuRREHTLrONFQEw1rH EHD PROPERTY OWNER NAME \ FIRST MI LAST PHONE NUMBER BUSINESS NAME I L4- f � Z .54'-)J E#IAILADDRESS � q-, Q OWNER HOME ADDRESS CmL ^ ` 11155 STATE ZIP � OWNER MAILING ADDRESS MAILING ADDRESS CITY STATE zip CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# ACCOUNT ID RNIRO# 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'P/ NO ❑ BUSINESSIFACILITY/SITE/PROJECT NAME I J l SITE ADDRESS/PROJECT LOCATION (v SUITE# BUSINESS PHONE CITY STATE zip J- 0 F�IF RVISOR DISTRICT �7 LOCATION CODE U KEY'I KEYZ SS, DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE zip SIC CODE APN# 97- —q rj COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME c 1 I / ATTENTION:ORCAREOF (OP770MALJ }JLL SIO J"I(� 4C COr/Jvl1•.s t/LIaS C— ��r WGJ1VwfY� MAILING ADDRESS ( PHO 7 r O�� l a✓ rr I b VX r CITY STATE zip Lbw (o� c-'q- Jl6 v ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLIN91(e BILLING AND CONIPLIANCE ACKNO\YLEDGMF.NT: 1,the undersigned Applicant,certify that I am the Owner,Operabrr,Arrthorfted Agent,ar Respomible Party and I acknowledge that all PERAfIr FL-FS', PF.A'AL77ES,E.t'FORCEILEM'CHdRGE.S and/or ffOURLYCDARGES associated With this project sill he billed to meal the address identirred above as the Accou.w ADDRESS'for this Site. I also certif,Y that all information provided on this application is true and correct;and that all regulated activities will be performed in accordance pith all applicable SAN JOAQUIN COUNIY ORDINANCE CODES and/or STANDARDS and STATE andfor FEDE2IL Lee's and REGULATIONS. As the undersigned Owner,Operator,Autlmrized Agent,ar Rnpumible Party 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 SAY JOAQUIN COUNTY FN-VIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or m'representative. r APPLICANT NAME(PLEASEPRINT) 1�\ SIGNATURE TITLE YYY _ TAx I D N APPROVED BY DATE ACCOUNTING OFFICE PROCE35ING COMPLETED BY DATE SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTN CHECK N RECEIVED BY WORK PLAN PE �S7 C FEE:s ✓7 S— �..Q,/y ��/SIFLs�. C,UC�.Y,%�i G J �