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San J 4 uin County Environmental Health 19-vartment <br /> i �► GREEN FORM <br /> DATE M STER FILE RECORD INFORMATION MFR SITE MITIGATION & LOP <br /> SHADED <br /> ^^ HD =O Y IW CASES UNIT IV <br /> OVMER FILE.CompLEirr rwFoLLOWMPROPERTY OWNER/NFOR.M{A770N: CnECxfFOWNERCURREynroN zLEwMEHDE1 <br /> PRDt'aRY DwItER NaME QFG CrAV I (ui) 4 -ybo <br /> First Mf Last PHONE Numset <br /> EiawLADORE89 <br /> BUMNFHB HANE O ? D /A <br /> e � GF r— (FI/1l..Co <br /> Owner Homo Addrma T./( E Q <br /> oily S T QC,K STATE LP q S Zob <br /> Owner Mailing Address <br /> O fn IK� �• <br /> Mailing Address city S .toLK.t C,,er aP 95a o <br /> PARTNERSHIP❑ FEDAOFNCY❑ OTHER 11 <br /> CDRPORATION/�, I�� <br /> Sire MmGA-nON_ENVIROMMWAL —VOLUNTARY CLEANUP—WATER QUALITY HW PIPELINE INVESTIGATION—LOP <br /> FAcanrYID# INV# AC ID PR#IRO# Aaa1GNED EMPLOYEE LEAD AGENCY:EH D_RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMP-M TNIEFOLLOYAW BUSINESS/FACILITY/SITE/NFORMA7i0N. <br /> Is this a NEW Business LOCATION rot previOU*regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? TO ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? Yes ❑ No <br /> BuslNEssJFAgUfY1SITENo,nE I,— <br /> %.—_n#^ <br /> a <br /> O /� <br /> SI1fIE# BU$INE99 PHONE <br /> SRE ADOREss <br /> I.fr r K A <br /> STATE LP <br /> CITY <br /> ST 957-0(c <br /> BOARDOF SUPERV190R DIATPICT i <br /> TION CODE I(EYd I,c,c <br /> Malling Address KC/FFERENr#wn Fi^WAd wto Attention:orCan Of(600naQ <br /> STATE LP <br /> Meiling Address City <br /> SICCODE AEN# CO1'O't�' <br /> RPILLING INS A <br /> Co/Hp1B� Billing Party is different <br /> THIRD B <br /> from Pro'p(e�lty Owner CrFacllity Operator identified above. <br /> BUNAME 1 J./`G wn:mC�Of(��d) <br /> AdvAoyap k, ,r /n Fn <br /> PHONE <br /> Melling Address, 9-3 /I O z05 -y6 7-/00 b <br /> C" 15 1 oC TO /LI C�'� Z/ <br /> s,5 S 5 <br /> AacaumrAaaffm forfees and Chief OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLMG AND COM LIANCa ACKNOW LARWO T: 1,00' igsrd Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that s,U PERMIT FEES, <br /> PE,yALTlrs,F.NFOR iawCIIAR and/or Hilt TOW wassociated with this opendo,will be billed tome at the address Identified above as the ACY TADOREEs for this slit. I oho certity That <br /> all toformation provided os,this appBotloe b One aM t-,and that an regulated activities will be performed in accordance with all applicable SAN JOAQM COUNTY Ordinance Codes and/or <br /> Standardslower do STATE ed on FEDERAL Lama and Reply os. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and Eli results and environmental asxnmut[Of. tion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTss soon ss ilis e and al the same Nme it is <br /> provided to me or my represeot.&C <br /> APPLICANT NAME(PLEASE PRINT) li�M GO f <br /> SIGNATURE <br /> TAx ID# <br /> TTS Pi{O £L i M N4&c <br /> rovod By Dab <br /> Accounting Office Processing Completed By Dab <br /> SITE MITIGATION ANou NTPAID DATE PAYMENT PAMENTTYPE RECEIPT# CHECK# RECENED BY WORK PLAN PE <br /> FEE:$ <br />