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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> « » GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> Emmm UNIT IV <br /> @HAOFOILEH"P-vj§Qwy OWNER IDS '/I W OI')I //J /' CASE A <br /> 94GO <br /> CHECR IF OWNER IS CURREwt it om FLEW?M EN D <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: / <br /> PROPERTYOWNERNMIE _ y j''7 ZoO <br /> FIa5r M! LAST PHONENUMBER <br /> E-MAIL ADOaEaB <br /> BUSINESS NAME <br /> OWNER HOME ADDRESS /I.V/\ l To,,mC Cat [ rc- T^` <br /> CITY <br /> if (! C ~JI 6_-�� 7JP <br /> "330 <br /> OWNER MAIUNO ADDRESS <br /> STATE 7jP <br /> MAILING ADDRESS CRY <br /> f Y�— <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP GOVERNMENT ADENCY ❑RF9PONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER DUALITY HW PIPELINE INVESTIGATION_LOP_ <br /> F ILtrYiDK INv► 1AqAoDcoquNDTtID5 <br /> PROIROt FA <br /> BSIONEDErPwYEE LEAD ADEN=EHD_— WGCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YEso NO ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ NO <br /> 14 <br /> BUSINEWFACILRYISRERROJECT NAME <br /> .�`-�O�M �✓c>"�/'r GIs f <br /> SREAODRFBBIPaoJECTLOCATION 0 <br /> SUITES B SINESSPHONE <br /> � � Q.r{�nn l�V�y �' <br /> ST TE Zip <br /> CRY ,l <br /> BOARD OF SUPERVISOR DIICT LOCATION CODE KEY1 KEY2 <br /> STR <br /> MAIUNO ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTTOrIAL) <br /> STATE ZIP <br /> MAIuNO ADDRESS CITY <br /> 0 COMMENT: <br /> AP <br /> SIC CODE <br /> l� a.�j <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> ATTENTION:CRCAREOF(OPRONAL) <br /> BUSINESS NAME <br /> Lt`J� CU <br /> MAIUNOADOREHS /� `rte / � // �J� �('� PHON '�I'` <br /> IU �1 L� V4AL1 C�J r. [ T(� 1. J V Y� <br /> CRT - � �TI�TE ZIP <br /> Scan PCArrn,�Ij rN <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLIN <br /> BILLING AND Os1W IANcE ACKSm\lEDG1tFNT: 1,the undersigned Applicant certify thot 1 am The Ou•nrral <br /> ,Operar,AurharLed Agent,or Rerpomible Parry'and 1 acknowledge ihai all PF.F.aIlT FFts, <br /> PEAVALRFS,ENFORCEIIEITCIIARGES and/or 11OURLT CHARGES associated with ills project will be bliled to me at the address Identified abawe As the.I000U,NTAODREU for(his site. 1 also certify That all <br /> Information provided on this application Is true and correct•,and that all regulated acNwities will be performed In accordance with dl npplicnble SAN JOAQUIN COUNTY ORDINANCE CODCS and/or <br /> STA.NDANDS and SLATE and/or FEDERAL Laws and REGULATIONS.As The undersigned ONTtar,Operator,Authorized Agent,or Respoaiible Parryfa a protect I a ve under racillty/site nddrrA 1 <br /> hereby anlhorire the release ornny and all nsvlts,reports,and other cnvironmentnl ncsessmenl Informotiun to SAN JOAQUIN COIATY E �L IIF I D PA HENT as soon as It is nvnilnble <br /> nod at the some time It is prodded to me or my"presentative. ^ <br /> APPLICANT NAME(PLEASE PRINT) I\L C k Q C� 64` V j/'Ci' SIGNATURE <br /> TITLE TAX ID# <br /> L n�lr�IlAVr, jClnn of <br /> APPROVED BY DAR <br /> ACCOUNMNO OrFlCE PRDCEa5l"G COMPLETED OY ATS <br /> SITEMRIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPTM CHE��IVEDI <br /> BY WORK E <br /> FEE:$ <br />