Laserfiche WebLink
n <br /> San Jc�uin County Environmental Health Di�ment <br /> is s'f GREEN FORM <br /> SATE jA MASTER FIDE RECORD INFORMATION MFR <br /> 1 ! — f 1 SITE MITIGATION& LOP <br /> SHADED AREAS FHD O OWNER ID# CASE# iI UNIT IV <br /> O <br /> OWNER FILE;COMALEfE FOLLOW/NG PRA ER INFQRMATi .N.' ? CNECXJF OWNER CURnRENTLYQNFl4EWITH EHD <br /> PROPERTYOWNERNAME W� I z1 +v <br /> Fiat Ml Last PHONE NUM13ER <br /> BUS E-MAILADORE55 <br /> SNAME <br /> +; rK Aft,. o <br /> tr,11:ameAddreea ;311 <br /> STATE ZIP QD 6 <br /> <S"t'�Ztin(G l <br /> I r <br /> MID <br /> Address / p 1 �k ley/ J ` <br /> � <br /> Stets <br /> Magi Address City 2lp 7 n 0 f 1 0 <br /> N fir 0� �` wl�S ,a (� <br /> -+. . ... OTHER�Q <br /> CORPORA ❑ INDIVIDUAL❑ PARTNERSHIP❑ FEO AGENCY❑ / <br /> SITE MITIGATION_ENylRON1Y11wNTAL A$SlSSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION^LOP <br /> FACILITY ID N INV# ACCOUNT IO PR R ASSIGNED E AZYEEFLEAO AGENCY:EHD_RWDCB_DTSC EPA <br /> Z 06�5t <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.'' <br /> 's a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No°. <br /> Isthis <br /> TION but a NEW TYPE of regulated Business? .� YES ❑ ND 1 <br /> Is this an EXISTING Business LOCA g <br /> BUSINESSIPACILIIVISITE NAME�``S-r C/,/ 1�gNiA, j a +r <br /> SI7EAPDRESS <br /> BE <br /> ( NN`1lt�IG1Y L t0. SUITE#- BUSINESS PHONE <br /> STATE Z(P -.. <br /> CIT S.Tc7cl�Tonc � ` . <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE= KEY1i KEY2 <br /> Mailing Address KDIFFERENTfrpmFacllltyAddress {! Attention:orCare Df(opllonaQ, <br /> PIS ✓6 <br /> EMallingAddressCity STATE ZIP <br /> -J�:2 16f _L000 <br /> E c - AEN# �r,, y <br /> U[0 <br /> I TNLRD PARTY BILLING INFO: Complete if Billing Party;ig�wkqjner orFaaility Operator identified above. <br /> BUVNE5S NAME .I Attentlon:orCare Of(Opf(mwl <br /> I <br /> Mailing Address PHONE <br /> CITY EFW10 <br /> Y STATE ZIP <br /> + ACCOUN.rA_poftESS forfess and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING ANP CONIPLEANCF.ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that f am the Owner,Opentror,or AnNutriLed Agerrr or this Business,and I acknowledge that all PERMrr FEES, <br /> PENAvaE5,ENFORCEAmffr CHAR(;E5 and/or HOURr yCuAROEv associated with this operation will be billed to me at(he address identified above as IheA(CYIUNTA!)ARF..CS for this Site. I also certify that <br /> fill informntion provided on this application is true and correct;and that all regulated activities will be performed in accordance with all appliealile SAN JOAQUIN COUNTY Ordinance Codes andlor <br /> Standards and STATE indlor FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above facility/site address,l lierehy authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL 14F.A1 TH DFPART'MENT as soon as it Is available and at the same time it is <br /> provided to me or my representative. g <br /> APPLICANT NAME{PLEEASEPRINT) ---';IMOrj jA6QqZfj4&- _ SIGNATURE <br /> TITLE p� l owl TAX Ip# � GS 2 <br /> I t4 <br /> Approved By Date Accounting Ofkite Processing Completed By Date <br /> SITEMITIGATION AMOUNTPAID DATEOFPAYMENT PAYMENTTYPE RECEIPT It CHECK# RECEIVED BY --WORK PLAN PE <br /> FEE: i <br /> i <br /> " y'Y <br /> f <br /> jp <br /> k- .U- .. rL11 <br /> __-- <br />