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0 • <br /> SAN aJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAB FOR EHD USE ONLY OWNER ID# CASE# IT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION. CHECK IF OWN(,U/-.> <br /> ER IS CURRRENTLYON FILE WITH EHD El <br /> PROPERTY OWNER NAMEFn tA � �Jer `�10) C,Ul r� �L; <br /> FIRST <br /> M1 LAST PHONE NUMBER <br /> /� E-MAILADDRESS 1 <br /> BUSINESS NAME r� /'I/ J (,/ L) r �11-3� 11 ,� "`f Ct Ie, CCI I-E t71 4^Ilm <br /> D c ruo (,L 1 t- <br /> OWNER HOME ADDRESS �� 7 f� / <br /> uDT <br /> !�� STATE ZIP <br /> CITY L C7 S f//��I n U Ll l1 elJ <br /> OWNER MAILING ADDRESS <br /> SLi fnc' <br /> MAILINGADDRESSCITY STATE ZIP <br /> J L <br /> CORPORATION [I INDIVIDUAL ❑PARTNERSHIP El GOVERNMENT AGENCY ❑RESPONSIBLE PARTY El OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACIu7YID# INV# AccaUNTID PR#IRO# ASSIGNED EMPLOYEE LeADAGEmy:EHD_}iWQCB_DTSC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ,❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES ❑ No�I <br /> BUSINESSIFACIUTYISTTE!PROJECT NAME - Die <br /> I it . <br /> SITE ADDRESS I PROJECT LOCATION /I— J (-�(J r /� SUrtE# BUSINESS PHONE <br /> .I s! Gr (![�I• 1Q I►1vI Pwl,ci.1 / -�/sV ;7 <br /> CRY ' STATE LP <br /> L CA«p <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE Ker1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OP77ONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF(OP7701144L) <br /> MAILING ADDRESS PHONE <br /> STATE ZIP <br /> CRY <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> RILLING AND COMPLIANCE ACKNOw'LEDG\LENT: I,the undersigned Applicant,certify lhm 1 am the On•ner,Operarnr,.4urbnrized Agen,or Respnm8k Party and I acknowledge that all PERanTFEFs, <br /> PENALIIFS,EYF0RCWIEATC714RCES and/or ll0URL1'C77dRCES associated with this project will he billed to me nt the address identified above as the ACCOLSATADDRFSS for this site. I also certify heat all <br /> information provided on this application is true and correct;and that nil regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUN-n'ORDINANCE CODES nndlor <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONs.As the undersigned Owner,Operator,Authorized Agen,or Responsible Parry for the project located above under facilitylsite address,1 <br /> hereby authorize the release orany and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is nvailablc <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAX ID# <br /> APPROVED By DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />