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San Jc jin County Environmental Health f artment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMAwN. CHEcKiF OWNER CVRRENaY0,VF1LE*wN EHD <br /> PROPERTY OWNER NAME -fj �q Gfr 'Cc Pt A /� L-� /L/U� _7-9? _91C (�, <br /> K- Fire 1_ , `MI Last `PHONE NUMBER <br /> 1 1 �t/ <br /> BUSINESS NAME E-MAILADDRESS <br /> ! LIMAS ACYL MAt-1IkCilhl(i ME EJELO ME�fT��IArtO ,Com <br /> Owner Home Address <br /> city 112F�G STATE zIP <br /> Owner Mailing Address <br /> 3z fk S rCe� <br /> Mailing Address City �'�! State Zip a S <br /> CORPORATION❑ r-r� INDIVIDUAL❑ PARTNERSHIP ElFEO AGENCY El1 OTHER❑ <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT IDPR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD�RWQCB DTSC_EPA <br /> 1 c, <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMATw <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEw TYPE of regulated Business? YES ❑ NoK <br /> BUSINESS/FAcILITY/Sn-E NAME <br /> lakc;q OFFICL L <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> (yon 4Z <br /> crrr TE ZIP <br /> CAIS <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifD/FFERENTfromfaci if ,Address Attention:orCare Of(opbona/J <br /> Mailing Address City /� STATE ZIP <br /> fft <br /> I , COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:or Care Of (opbona/J <br /> � CNJI ti �A c J GE rJC. <br /> Mailing Address PHONE <br /> 1-110 CS►r, g3� -3-I00 <br /> CITY sTGA � <br /> fbr fees and charges OWNER FACILaylBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 aclmow ge that all PERWT FFF..Y, <br /> PENALTIE4,ENFORCEMENT CHARGES and/or HOURLPCRARGFS associated with this operation will be baled tome at the address identified above as the ACCVVNTADDR=for thispl_so certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with ag applicable SAN JOAQUIN COt7N7V O I �tt'' �C <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby s4l�iyfae /f <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at I^k <br /> provided to me or my representative. 12 <br /> Cl <br /> APPLICANT NAME(PLEASE PRINT) C��L/_ l DEl� SIGNATURE 2 6 1"0 <br /> TITS TAX ID# ENVIq U(N COU <br /> 1 R C`? nC�� i ?cv 115 `�NEAt OI(�EN N1Y <br /> Approved 8 �{)sad%�c L Date 7 17 Accounting Office Processing Completed By Date N <br /> SITE MITIGATIONt-� AMOUNT PAID DATE OF P'AIY1MEINT PAYMENT TYPE RECEIPT# CHECK#F RECEIVED BY WORK PLAN PE <br /> FEE: 1 l5 v I � ( 5& l <br />