Laserfiche WebLink
San Juin County Environmental HealtWartment Gr-RwIt— <br /> DATE O I l('L MASTER FILE RECORD INFORMATION "MFRI' GREEN FORM <br /> oozy 9771 <br /> SITE MITIGATION & LOP <br /> SMDEO AREAS F0 •/�y/ <br /> EHD USE OWNER ID# � 1 l GAGE# <br /> 5R-o 01-4-1-71 UNIT IV <br /> OWNER FILE:COMPLETE TIHEFOLLowAAGPROPERTY OWNER INFORMA7ww CHETScirOWNER CuRREem.roNneemrHEHDEl <br /> PROPERTY OWNER NAME ( ley' ( — 2.7yo <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME E44AIL ADDRESS <br /> Owner Home Addrme )0L5 Al 5 ,��T.,� ©� <br /> city �7 OGI,C-1'w rM.+ STATE L <br /> Owner Mailing Address 7,,II <br /> L <br /> Melling Addi esa City S47oat� � ..- Zip �S�✓.zj <br /> CORPORATION❑ INDIVIDUAL], PARTNERSHIP❑ FED AGENCY El OTHER 11 <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILIWID# INV# ACCOUNTID PR O# ASSIGNED EMPLOYEE LEAn AGENCY:EHD_RWQCB_DTSC_EPA- <br /> 33EIlif D537o81 <br /> FACILITY FILE COMPLETETHEFOLLOW/NO BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES,O No ❑ <br /> Is this an E%ISTING Business LAOATION but a NEW TYPE of regulated Business? YES 0' No ❑ <br /> SUSINESWFACILTTYISHENAME <br /> SITEADDRESS q�(, SUITE# BU81NE99 PHONE_��O <br /> CITY (l,,r / STATE 7jP - <br /> SS D S <br /> SOAROGF SUPERVISOR DIMILT LOCATION CODE Kul IEY2 <br /> Melling Address ffOIFFERENTfronr FscffRyAddi ass Attention:orCare Of(opUbnatf <br /> Mailing Address City STATE ZIP <br /> SIC CooE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNmE / 1 Attention:orCam Of(Cpffo/ral) Tri^ 1 <br /> Mailing Address `0 3 7 <br /> CITY S4,o cki acs STATE 01� ZJP Kl 1 <br /> J <br /> AcaGURrALN�aEAs for fees and charges OWNER FACILITY/BUSINESS ans THIRDPARTYBILLING <br /> BUJMG AND COMPLUNeB ACKHOWLEDGMERT: 1,the undersigned Applicant,certify that I am the owner,Operator,or Authored Agent of this Business,and I acknowledge that ail PEasin,"a, <br /> PEN,1LTiss,ENFozzt: NfCn ss and/or RODRLYChMGES associated with this operation will be bitted to meat the address identified above w the Ar xtczyrADORFcs for this situ I also certify that <br /> all information provided on this application is trse and correct;and that all regulated activities will be performed in accordance with all applicable SAH JOAQUIN COIINTY Ordinance Coda and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undenigoed owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and ail ranks and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART ENT As no A u 'able,and at the same time it is <br /> provided to me or my representative. f� / <br /> APPLICANT NAME(PLEASE PRINT) // / !�//9��1) SIGNATURE ] — <br /> TITLE FAX ID# <br /> Approved BY Dale AccountlnB OBka Proeeeaine CamPleGd By '] Dwate / J Z� <br /> SITE MITIGATION cL�AMOUNT PLAIDTATEOFPA�YJMENT PAYMENTTYPE RECEIPT# CHECK#9 RECEIVED BY W00.K PLAN PE <br /> FEE: J /S� 3 I J 1 (1 � ��O I L 9 �U <br />