Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
SAN J, .IUIN COUNTY ENVIRONMENTAL HEALTH L aRTMENT <br /> DATE /�D // MASTER FILE RECORD INFORMATION MFR P1 GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDS CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLYONFILE W/rH EHD E1 <br /> PROPERTY OWNER NAMETgAC or=�Icc- , �-�.- 005) 7-- 9 9 C/�o <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> _FMC OEE:r10KAZA Lu, - THO 13 CRL rA4 6W,ea� <br /> OWNER HOME ADDRESS <br /> 32 <br /> cm (n n L STA Q LP <br /> �7 J1 — .7& <br /> OWNER MAILING ADDRESS 3 2 <br /> MAILING ADDRESS CITY STATE zip <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_�,-VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID p LINV* <br /> ACCOUNT ID IP <br /> R#IRO# ASSIGNED EMPLOYEE PEAD AGENCY:EHDRWQCB_DTSC_EPA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No a <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES,®1 No ❑ <br /> BUSINESS/FACILITY/SITE/PROJECT NAME TgAc c t'r I-C y / qZA <br /> SITE ADDRESS/PROJECT LOCATION IS SUITE# BUSINESS PHONE <br /> _>2 Ll C C 409 z Z <br /> CITY .J)Zn/ q STATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILING ADDRESS CITY STATE zip <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME Bi/Vr A N v!R0 NM AJ/)qL, 5- =C T C ATTENTION:ORCARE OF OPTIONAL) <br /> MAILING ADDRESS J- PHONE <br /> lO PANKc-zti STPE&T LAVrC- Zoo A /0) 03k- 3700 <br /> CITY TSZIP <br /> 0A <br /> k,L 1A,A"D <br /> /[]E I Z /2— <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER* FACILITY/BUSINESS❑ THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applican4 certify that I aro the Owner,Operator,Authorized Agent,or Responsible Party and I acknowledge that all PERWT FEES, <br /> PEA:1L77Es,EnFoRCEMENTCHARGES and/or HouRLY CHARGES associated with this project will be billed tome at the address identified above as the ACCOUNT ADDRESS for this site. I also certify that all's <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agent,or Responsible Parry for the project located above under facility/site address <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avails a \J <br /> and at the same time it is provided to me or my representative. 'I�� � k�'APPLICANT NAME(PLEASE PRINT) SIGNATURE 'A-11C `' <br /> 1305 C L.AP- - gr.DDr L i V x r C�' <br /> TITLE PP-&,5 <br /> f7&S DCN TAx ID# Z✓ —16152-39 <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BYRZf N PE <br /> FEE:$ GJs 7 <br />