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_ Sar '-aquin County Environmental Heal apartment <br /> DATE Qr . p r I KTER FILE RECORD INFORMATION Te'r^Rss GREEN FORM <br /> / SITE MITIGATION&LOP <br /> SHAOEO AREAS FOR EHD ON OWNER ID# 6 IZ,. DASE# T UNIT IV <br /> /WNMRPILE:COMPLETETHEFOLLOW(NGPROPER IIITYOWNERlwomeiir7ow=E�ILADORnS <br /> VIJCHECKIFOWNER CURRENnrONRLEWTrNEMD El <br /> PROPERTY OWNER NAME <br /> First MIELastBUSINESS NAME <br /> Owner Home Ad dress <br /> city <br /> Owner Mailing Address <br /> .2yS �a.rkfi-ef�.�e o�lt �''/nor <br /> Malling Address City <br /> ZIP '�- <br /> CORPORATION❑ INDOf <br /> IVIDUAL❑ PARTNERSHIP❑ FED AGENCY El OTHER❑ <br /> / •, <br /> SITE MfnaATION_ENVIRONMENTAL Ai#ltOMINT G VOLUNTARY CLEANUP__WATER QYALRT_HW PIPELINE INV IBT TON_ LOP_ <br /> FACILITY IO INv# AccouaTlD 11111:11 M`# AssmOeo EMPL vee LEAP AeeYet:EHD WqC T$C_EPA_ <br /> 1 S-yo <br /> FACILITYFILE CovmErE 7HEFOLLOW/NG BUSINESS/FACILITY/SITE fNroRMAYtom- <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yEs ❑ No <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? yEs ❑ No <br /> BuswessIFACILITY/SITE NAME <br /> SITEADORESS <br /> SUITE# BUSINESSPHONE <br /> CITY /fi ` t <br /> % $TpTE <br /> r�cS '76 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEYt REY2 --- <br /> Mailing Address ND/FFERENThorn Fac#/tyAtydroas Attendant t»Care Of(opNorm// <br /> 3 3 Ea3G b <br /> Mailing Address City / J /�ST�AjE ZIP <br /> ..i'TT C'_. ./7 <br /> SIC CODE APN# COMMENT: - <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner OrFecility Operator identifiedabove. <br /> BUSINESsNmE }P//7 7 / /,e, ) Ad► nyOFCare Of(OpNdra// <br /> Mailing Address <br /> /ff i1VFs7� /re,< i`v cf _ � PHON <br /> YG, <br /> /'?/<�--7S S a <br /> CITY STATE ZIP <br /> AccouNrAlaagEss for fees and charges OWNER FAciuTYBUSINESS THIRD PARTY BIWNG <br /> Bu.LpvG AND CONBL CE AClrno WLEDGW¢ : I,the ou dersigned Apphcan4 cerdfy that I.the Owns,Opermor,or AWhonzed Agent of this Business,and I aclmowledge drat a6 PeRSDT FPes, <br /> PeNALTTgS,E,NFDRCEsfFxr CaaRGEs and/or RDUR[➢CNwxces usociand with alio aperadoo w61 be billed m meat Weaddraa idena6ed above u the ACCDUATADDRELT for thu site. I also cerdfv drat <br /> all mforsnstian pravided on this application is live and correct and that all regulated acdvida will be performed m accbrdaoce with ell applicable SAN JDAQsmf CODNIY Ordioavice Codn and/or <br /> Standards and STATE and/or FEDERg Laws and Regulations. As We smdersi ned owner,operator,or agent of the property located at the above facility/aim address,I hereby authorize the release of <br /> any and au resWta and mviroomental assessment inforsrsadon to SAN JOAQUIN COUNEy ENVIRONMENTAL IFAI TTi'DEPART.WNT v soon as it is available and at the same time it is <br /> provided to.,.e my repromtative `. <br /> APPLICANT NAME(PLEASE PRINT) ! j e 11;1/�,/—s � ���os $IGNANRE✓� <br /> Approved By v Data Accounting Office Prucesaina Completed BySITE oiTe <br /> FEE:$ TIG AMOUNT PAID DATE O�PAYMENT PA�TYPERECEW7# CH � � RECZIVED BY WORFEE:_ ,4/IvYa/�/4 <br /> I <br />