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BUSINESS NAME v.....„....zjict4 <br />C N.'7V-, ( 1%4 C <br />MAILING ADDRESS A-t) <br />ATTENTION: ORCARE OF (OPT/ONAL) <br />PIES <br />DATE 31-1 IR" <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />MASTER FILE RECORD INFORMATION "MFR" <br />OWNER ID* <br /> <br />CASE* SHADED A/MAE FOR END USE ONLY <br />GREEN FORM <br />SITE MITIGATION & LOP <br />UNIT IV <br />OWNER FILE : COMPLETE PROPERTY OWNER/ RESPONSIBLE PARTY INFORMATION: CHECK If OWNER IS CURRENTLY ON FILE WITH END <br />PROPERTY OWNER NAME c...cy c L....Lc_ (20 5 <br />.._.- <br />FIRST MI LAST PHONE NUMBER <br />BUSINESS NAME r ---t.) L--T k ---c-i_t-t .4--1.-N- co v—c_p_c_k 4‘ t D EY- <br />E-MAIL ADDRESS e___A_Tcr4,EA-2,_•( e N 14;f1PA-0-4.1.41 <br />OWNER HOME ADDRESS <br />CITY STATE ZIP <br />OWNER MAILING ADDRESS <br />.. 0 - B 01c. 2_0 <br />MAIUNG ADDRESS CITY <br />g 1- 0 C.. ke...-7 0 0 <br />STF., ZIP I <br />LY'' 5-20 I <br />D CosPoRAncm <br /> <br />0 INDIVIDUAL <br /> <br />0 PARTNERSHIP <br /> <br />0 GOVERNMENT AGENCY 0 RESPONSIBLE PARTY <br /> D CrrHER <br />SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP)( WATER OUALJTY HW Pipeume INVESTIGATION LOP <br />SIGNATURE <br />FAciury ID 0 <br />&bZIE7.0 <br />Accouirr ID ji Reif ASSIGNED EMPLOYEE <br />65-37 02_. 1I-(53 <br />LEAD AGENCY. EHD )( RWCOIll DISC EPA <br /> <br />FACILITY FILE: COMPLETE BUSINESS I SITE/ PROJECT INFORMATION: <br />IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES NO 0 <br />IS THIS AN EXISTING PROJECT LOCATION, BUT A NEW SCOPE OF WORK? YES El No K <br />BussiEss(FAciLnYONTERRomoT NAME <br /> ( C o t4 ut-f- PP-OPc-e---Ci <br />SIVE ADMEN! t PROJECT LOCATION 3 q _ . SUITES BUSINESS PHONE <br />Crrr Srocr=rot-1 d3X11E. ZIP <br />BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYI KEr2 1 <br /> <br />MAILING ADDRESS , IF DIFFERENT FROM FACILITY ADDRESS ATTENTION: ORCARE OF (OP <br />0 .. 6oic ?..x) cy_3-5_ Luc__ (A11_0 L._ C-EE KO U....A-14 Cie) P-01) #c <br />MAILING ADDRESS CrrY STATE Zip' <br />f-T-40 (-ACT-0 1.4 C_Ic 1 c20 1 <br />SIC CODE APN 0 Cowen <br />THIRD PARTY BILLING INFO COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br />CITY <br />Ct.-6 11/4,S <br />STATE crk- <br />ACCOUNT ADDRESS To SEND FEES AND CHARGES: OVVNERO FACILITY(BUSIN ESSE! THIRD PARTY BILLING <br />DILLING AND COMPLIANCE ACKNOWLEDGMENT: I, the undersigned Applimmt, certify that I am the Owner, Operator, Ataborlzed Agent, or Resportsible Party and I acknowledge that all PERMIT FEES, <br />PENAtries, ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this project will be billed to me at the address identified above as the A ccot vrAGGazss for this eke. I abo certify that all <br />Information provided on this application is tree and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN Cowry ORDINANCE CODES and/or <br />STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the tmdersrivsed Owner, Operator, Authodzed Agent, or Responsible Party for the project located above under facility/site address, I <br />hereby authorize the release of any and all results, reports, and other ervironmental assessment information to SAN JOAQUIN Cowry ENVIRONMENp ILALTH DEPARTMENT as available <br />and at the same time It is provided to me or my representative. <br />APPLICANT NA GE (PLEASE PRINT) rodkikci.._--/—‘ 1-1-0 <br />TinE Lii P/j-T/ACL- kA•TE R_. <br />i /kppROVED Bk_A-I-e--- DATE .S/3/7/ 41 AcCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br />SITE MITIGATION AMOUNT PAID DATE oF PAYMENT PAYMENT TYPE , RECgT ;V CHECK* RECEIVED BY WORK PLAN PE