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San Joaquin County Environmental Health "lial-nent DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM �77SITE MITIGATION &LOP SHADED AREAS FOR EHD USE ONLY OWNER ID#Du7 nI Q) CASE# UNIT IV OWNER FILE:CoMPLETEPROPERTY OWNER/RESPONSIBLE PARTY/NFoRwTloN: CHECKIF OWNER CURRENTLY ON FILE WITH EHD El PROPERTY OWNER NAME Tor•\ R L/�I,. ('�p� Z L/Z -q99(.. First MI Last PHONE NUMBER BUSINESS NAME 1 A C Y O F r I�E- P L ,`H t+ A\ LLC E-MAIL ADDRESS K srl3 Int:VE LO?in rJ 7 G Owner Home Address 1 _ S j L 2 l-.ViC .lX ti0 cityI STATE ZIP ,Ji /4LA 'h IT-LJ C /� `�L fZ`' Owner Mailing Address J Hn'1 CJ A N 6 A Mailing Address City State Zip ,CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP PEPL% ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP�t WATER QUALITY_HW PIPELINE INVESTIGATION LOP FACILITY ID# INV# ACCOUNT ID PR#/, # ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC_EPA 14CO22--n '-��q19 j44)9q/sric) rzas�9�sZ ��4�� 00D _ FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT/NFORMAT/oN: Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No ❑ BUSINESS/FACILITY/SITE/PROJECT NAME ,.., I �.�(. VI-I'I Lr 1'4-"1 �..` SITE ADDRESS I PROJECT LOCATION 32-LI r, ;h s► SUITE# BUSINESS PHONE ► I CITY I STATE e 3J L BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 Mailing Address it'D/FFERENTfrom Facility Address Attention:or Care Of(optional) I -L�G I S /L✓Isi(L TDm 13LA"k-- Mailing Address City STATE ZIP!� LOS ALAmfT01 Fy4 ry0 , Z SIC CODE APNi COMMENT: �n -1 C -b,i, THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. BUSINESS NAME Attention:orCare Of (optional) Mailing Address PHONE CITY STATE ZIP AccouNZADDRESS for fees and charges OWNS FACILITY/BUSINESS THIRD PARTY BILLING Hu.t.INC ASD( 1,the undersigned Applicant,certify that lam the(teener,Operator--Iuthori:ed Igent,or Respn1trih1e Purtland I acknowledge that all PI:R]Hl llxl , P1n I1.I7FS,E\R)RCEh1E.A'1'01.IR6E.v and/or 1/01 R1.1 CHARGES IISSoeiated with this project will he billed to ine at the address identified above as the:k(oyAl ADDRESSfor this site. I also certify that all information provided on this application is true and correct:and that ail regulated actisitics will he performed in accordance with all applicable SAN,IOAQUIN COUNTY Ordinance('odes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Otvner,Operator,Authorised Agent,or Respotvsible Party for the project located above tinder facility'/site address,I hereby authorize the release of am•and all results,reports,and other em-ironmental assessment information to S:AN.IOAQI'IN('01'NTN'ENN I RONMENTAL HEALTH DEPARTNI EN"has somas it is available and at the same time it is provided to me or my representative. APPLICANT NAME(PLEASE PRINT) I �V/h�� 3iq SIGNATURE TITLE TAx ID#I�A�I A•'r,L �1 '—�-,l!��1 �'v Approved By Date Accounting Office Processing Completed By Date SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVEn BY WORKPLANP FEE:$W 5b^ L. t KP!v3