Laserfiche WebLink
o - 1 - 1011 •, ivironmental Health De <br /> M'0�R FILE RECO Department <br /> RD INFORMATION Ir <br /> A RPS FDR "° ON Y � GREEN FORM <br /> OWNER FILE: OWNER ID# <br /> COMPLE7E?IyEFOLLOAVtgfGPROPERTY O ICA11# SITE MITIGATION& LOP <br /> PROPERTY OWNER NAME UNIT IV <br /> WNER/NFORMg7TON.' <br /> BUSINESS NAME as FifeSQf lat t(r M/ <br /> Uwrr1MOrld <br /> cHEnr/F OP <br /> WHNONEER NCUuMBREERN <br /> n y0Nricea <br /> rH EHO <br /> urk(O'l PQLast (402) Sgcf -R 24 <br /> Ho ma gtltlr <br /> EMAILADDRESS <br /> city 1-4AMM ONp@ U P,G'" <br /> Owner Mailing Address r, DC <br /> _lo0 C STATE 21P <br /> Mailing Address Ci _I ISS 4rCG+ STop <br /> Iry Dma(�lo„ IC30 <br /> CORPORATION') State Zi <br /> IND IVI11 DU11 AL❑ N`+ P6�t-19_/ 30 <br /> PARTNERSMIP0 <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT ✓ FEDAGENCY❑ <br /> VOLUNTARY LYEANUP OTHER <br /> FACILItt ID# INV# _WATER QUALITY_Hyy PIPELINE INVESTI <br /> ACCOUNT IO PR#/RO# OATION_LOP <br /> ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPq <br /> FACILITYFILE C0MPLE7E7ttEF0LL0W/NG BUSINESS/FACILITY/SITE//VFo,.,,,oN.• <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPAR <br /> IS thiS an EI°STING BUSIne3s LOCATION but a NEW TYPE Of regulated Business? TMENT? YES No ❑ <br /> BUSINESSIFACRRYISITE NAME lJ r 1n(Dn fIu ❑ ❑ <br /> (a �tc Ra;lroad - Rcc-T YES NO F� <br /> Ptjr <br /> $ITE ADptESss IDOL <br /> /1 O �� M P 95.16 Dak4�,,,� Sa,b� e SURE# BUSINESS PHONE <br /> CITY <br /> FM' STATE ZIP <br /> � 95231 <br /> BOARD OFS 4ERVISOR DISTRICT LOCATION CODE KEYS <br /> KEr2 <br /> Mailing Address ilD/FFEREiVrhromFauT31AaH— <br /> I 40C J a �4r STCP 1 30 Attantlan:wCare Of(opLona/J <br /> Mailing Address City / w' I" �- VI <br /> D/r1O-✓t Ll STATE LP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete it Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME t � / <br /> CDr1� AMCdt - V °I ASSrxl�tG Attention:arCare /opNwra9 <br /> Mailing Address rr G <br /> 5`100 Ili a SuNe "PIG <br /> CITY tv -y2D -o�oa <br /> �m V I Il'L STATE zP <br /> LllvO <br /> Acca A Dw for fees and charges <br /> OWNER FACILITY/BUSINESS <br />'LbING AND(OMm,Avw ACKNO THIRD PARTY BILLING ✓ <br /> LEDr 1,the undersigned Applicant,certify that 1 am the Owner,Operator,Or Audmrked Agent of this Business,and 1 acknowledge that all PERM/r FEmq <br /> informs,ErvrProvided on this <br /> applic/or RDURLYCNARGES associated with this Operation will be billed to ,at the address idenfified above as the AccOpNTAnDRFSs for this site. 1 also certify that <br /> information provided an this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN LXrAD R COUNTY Ordinance Codes c es and/or <br /> Indards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,Operator,Or agent If the property located at the above facility/site address,I hereby authorize the release of <br /> I,and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />'Y'ded to me or my representative. <br /> RPLICANT NAME(PLEASE PRINT) RaN ,SC <br /> E< L SIGNATURE <br /> 1TLEsy . 1 ` CDA TAX ID# <br /> -------------------- <br />,pproVed By D [e Attounting Office Prose>sing Gum feted By <br /> Dem <br /> 11TEMITIGATION AMDUNTPAID DATE co, YMENT PAYMENTTYPE RECEIPT# CHECK#'T- RECEIVED By WORK PLAN PE <br /> FEE:$ <br />