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San Juin County Environmental Health Oartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> n SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USEONLY OWNERID#600Q�1l�Z. CAGE# UNIT IV <br /> OWNER FILE:CaWPLE/EPROPERTYOWNER!RESPONSIBLE PARTY/NfoRMArlom CNLvw/rOWNER Cuaaranroar/IuEwnHEND <br /> � <br /> PROPERTY OWNER NAME /i1.YD l IC 7 <br /> First MI Last PNONENUMBER �u�,4KVSSA.- ZI' l! <br /> BUSINEss NAME /' IMMNLAnompls <br /> U .v <br /> Owner Home Addrew <br /> �V <br /> DNI' STATE LP� 772)7 <br /> Owner Melling Address 00 S U <br /> Melling Address City ,.,/ G / A "'C19-M,-77 <br /> ❑CORPORATION 1-1INDIVIDUAL [I PARTNERSHIP Ly GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑GrHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP _WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACIun 10 INV# ACCOUNTIO FR#lop ASSIGNED EMPLOYEE LEAD AGENCY:END RWOCB_DTSC_EPA <br /> �/Qota2�310 t42LxrFL�F3 �n-os�Fty-h� <br /> FACILITY FILE: ComPLETE BUSINESS/SITE/PROJECT/NFORMwitom <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES t>;' No ❑ <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No <br /> BUSINEea1FAcaUTY/SREIPRQIECT NAME <br /> Y <br /> SITE ADDRESS/PROJECT LOCATIONUITE# UBINEwP ONE <br /> Q <br /> CITY Sr�re LP^ 7 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYT KEYY22 (� <br /> Malling Addrew/fD/FF£RENTfrom Fac!/ltyAddraw Attention:or-Care Of(optbnell) <br /> Melling Address City �Y I 1 A !j STATE 'PC <br /> 2 <br /> C� J <br /> SIC CGDE APN!� f/p-�® COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different fmmProperty Owner Or Responsible Party%dent%fiedaboVe. <br /> BUSINESS NAME Attention:arcane Of (OuiVana/J <br /> Mailing Address PHONE <br /> CITY STATE ZIP <br /> Aft' yrAaaww for few and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,cerdfy Met 1 am Me(Aswer,(Iperaton Authorized Agent,or Responsible Part),and 1 acknowledge that all PE"ITFEE5, <br /> PENALTLES,ENFYIRCEMEVr CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at Me address identified above as the ACCOUNTA ams for this site. I also certify that all <br /> information provided on this application ts true and correct;and that all regulated aadvides will be performed in accordance with all applicable SAN JOAQUIN DOuNry Ordinvnte Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Reguladom. As Me undersigned Owner,Operator AUMori ed Agent,or Responsible Party for the project located above Under facility/site address,l <br /> hereby mol orie the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided in meJ or my representative.�) <br /> APPLICANT NAME(PLEASE PRINT)IAN Wn�?IA YJAYIY\ W I A!, I10 SIGNATURE — <br /> TITLE 1 TAX ID# <br /> ..d By Date AeeZ;ng Office Processing Completed By Date <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT PAYMEw TYPE RECEIPT# CHECK# RECEIVED BY WORK PIAN PE <br /> FEE:$ <br />