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San JV-,-iuin County Environmental Health r apartment <br /> DATE Mt ?JR FILE RECORD INFORMATION 911V'4" GREEN FORM <br /> 1b �� �� SITE MITIGATION & LOP <br /> SHADED AREASFOR EHD USE ONLY OVVWAID/ CASEI, <br /> fj rti (nK UNIT IV <br /> pN <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY INFORMAnoIv- CHECK IF OWN ER Cl/R�R]EMLYONFILfiYITH EMO <br /> PROPERTY OWNER NAME ' via t1l) 'f <br /> First M, Last PHONE NUMBER <br /> BU91Ness NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE ZJP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> ❑CORPORATION INDIVIDUAL ElPARTNERSHIP El C+oVERNMENT AGENCY ElRESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION j_//ENVIRONMENTAL ASSESSMENT_VOLUNT RY CLEANUP_WATER QUALITY_HW PIPELINE I VESTIGATION_LOP <br /> FACttmtOf IrtvlM AaoauttrlDD <br /> WtortmEllrtoYn La"Atemv:EHD RWgCB_by= 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 <br /> Is this an E)asnNG Project LOCATION but a NEW SCOPE OF WORK? YES No <br /> CI ❑ <br /> BUSINESSIFALITYISITEIPROJECT NAME A[t r,W p o /} <br /> p Q4r ( L <br /> SITE ADDRESS IPROJECTLOCATION �j �r f , [L I rl? SUITE# BUSINESS HONE <br /> CITY1 '404,`��{�/` �Lf STAT ZIP <br /> .BomooF8ummeoNDIsmar il`LoCA`/ TIDNNCooe KEY1 -KEY2 <br /> Mailing Address lfDIFFER )VTfrom FacllityPAdd�s Attention:orCare OF(optlonal) <br /> ! {� <br /> Mailing Address City 4 <br /> G 1 y STAZ t, Zip 9 <br /> 8IC CaDE APN iI f�— 7t1 CGOWENT: t rl1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identifiedabove. <br /> BUSINESS NAME + t Jy.,,t � !vtc,. Attention:orCare Qf (opHonal) <br /> Halling Address 7 r79d oc v ot U GL f'i'' <br /> oITY ` eti J e� STATE�j1 ZIP <br /> for fees and chargee mfr HIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Authorized Agent,or Responsible Party an ERMrr FEES, <br /> PavALTIES,ENFORCEMENTCff RGFs and/or HOURLYCHARGES associated with this project will be billed to me at the address identified above as the ACCOWTADDRFS4 for this site. I also cerfiry that all <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 Party for project located above under facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENV N IENTA HEA DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PRASE PRINT) SIGNATURE /Z'1 <br /> TITLE TAX IDS <br /> 1151 by,57 <br /> t.�$ <br /> d eyDate Accounting Office Proceeeing Completed By Date1iW►T" Attu uw PAID DATE OF PAYMENT PAYMENTTYPE REOERMT S CHECK f REOPJVE6 BY WORK PLAN PE <br />