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San Jouin County Environmental Healthdiii.epartment <br /> DATE J> I/ /�,L M .. ER FILE RECORD INFORMATION SLI IR GREENFORM <br /> l / SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNERID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NGPROPERTY OWNER INFORMA77oN. CNECN/F OWNER CU RRENTLyome1LEwrHEHD � <br /> PRoPERIYOmma NAGE ( 1 (/I�A — <br /> First MI L Last P'HHOONrE/NUMBER <br /> BUSINESS NAME IVr�f.V / E-MAILADDRESs <br /> Owner Home Address �DRV'CS�I1�nIT� <br /> ©�E <br /> city <br /> cin, <br /> Owner Melling Address q szp A00 <br /> She /J <br /> Mtdling Address City 7Jp <br /> coRmRATION❑ INOIWDOA�,O PARTNERSHIP FED AGENCY El OTHER El <br /> SITE MITIGATION_ENVIRONMENTAL Assimmo scr_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITYID# INV# ACCOUNTID PR#IRO# AssIGNED EMPLOY EE LEAD AGENCY:EHD RWQCB_OTSC_EPA_ <br /> FACILITYFILE COMPLETETHEFOLLOW/NGBUSINESS/FACILITY/SITE INFORMAlww <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEsZ No ❑ <br /> Is this an ExHITING Business LOCATION but a NEW Prw of regulated Business? YEB fa' No ❑ <br /> BUSINESSIFACII ISITENAME <br /> SREADDRESS 5 0 /� �„^ / �� SURE# BUSIN: PHONE _�L Q <br /> CITY / ,,t / �v STATE LP54PCJS /7s` <br /> V P///V`IL D J <br /> BOARDOFSUPERVISOR DISTRICT LOCATION CODE Kul KEYS <br /> Mailing Address,heDlf7ERENrinvest Fad///yAddrsss Attention:orCara Of fops/1 <br /> Melling Address City STATE LP <br /> SIC CODE APG# COMMENT: <br /> THIRD PARTY BI1LLING INFO: Complete if Billing Party is different from Property Owner orFaciiity Operator idenUFied above. <br /> BUSINESS NAME / J Attention:orCare Of t0/!NO/Y/1 raj rip^ t <br /> Mailing Address 63-7 S I _ PHONE 47—tt�� <br /> CITY � r, n (N STATE czip i <br /> Ag2D(/AQApOB6S4 forfees and charges OWNER FACILITY/BUSINESS THIRDPARTYBILLING , <br /> BILLING AND COMPLlsttl E ACKNOwLRDGMENr: L the undersigned Appticantq certify,that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all P£Rsirr FEES, <br /> PENAL ,ENPost:nziEw CnAiwzS and/or//OURLY CHARGES associated with this operation will be billed to me at the address identified above as the ACYYIrwyrAODItFSS 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 JOAQUgV COUNTY Ordinance Codes and/or <br /> Standards and$TATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at We 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 DEPART NT aalpon it u able and the same time it u <br /> /////// <br /> provided to me or my representative, <br /> APPIJCANT NAME(PLEASE PRINT)-r7 / Jj7�{� SIGNATURE <br /> TITLE ✓I Lam` TAX ID# <br /> Approved By V Dab Accwnting Office Processing Completed By J Gw <br /> SITE MITIGATION AMOUNT PAID DATEOF PAYMENT PAYMENT TrPE RECEIPT# CHECK It RECEIVED BY WORK PLAN PE <br /> FEE: <br /> -11 <br />