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San JO al County Environmental Health D rtment <br /> DATE MASR FILE RECORD INFORMATION IIMt GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHO USE ONLY OWNERID# n CASE# UNIT IV <br /> Oto 2 l � <br /> OWNER FILE:COMPLETE THEFOLLOWINO PROPERTY OWNERINFoRMATIoN. CHECK/F OWNER CURRENTLYDNFILEW/TH EHDEl <br /> PROPERTY OWNER NAME CI - Al (; ) <br /> First r MI I Last PHONE NUMBER <br /> BUSINESS NAME �' I -� O/t ,�51 � NI,I u n'e AL 5 1 EMAILADDRESS <br /> Owner Home Address <br /> 7S01> <br /> city `J G K -1a iii STATE/Ir, ZIP�� <br /> Owner Mailing Address <br /> Mailing Address City State ZIP <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHE <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACQOUNTID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB_DTSC_EPA_ <br /> flDD 0 Q.� 3lie.172A MS3560 <br /> FACILITYFILE COMPLETETHEFOLLOw/NOBUSINESSI FACILITY/SITE INFORMATION. <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 ❑ No ❑ <br /> BUSINESS/FACIE ST Nftr.)E,a,e E 1,, 44 <br /> kl T yf� �� <br /> SITEADDRESS (fes Jv ��__�r WGA _O yam_ ) 1 ` ^ W I /rt SUITE# BUSINESS PHONE <br /> 1973 N <br /> CITY STATE 21P <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address WDIFFERENTfrom FacililyAddrass Attention:or Care Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> D5�03DOZ <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identiffedabove. <br /> BUSINESS NAME KW"MLJ( x.,rAttention:or Care Of (optional) <br /> MailingAddress AOYL 9ok PHONE zp r <br /> CITY <br /> �+ 1 STA ZIP S2"r, <br /> ACCOUNTADORFSS for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COaIPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,cerdfv that 1 am the Owner,Operator,or Authorized Agent of 1Ns Business,and I acknowledge that all PERAHTFEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/Dr HOURLYCHARG£5 associated with this operation will be billed tome at the address Identified above as the ACCOUNTADDREss for this Site. I also certify 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 JOAQVIN COUNTv Ordinance Codes and/or <br /> Standards and STATE and/or FEDERu Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR NT as soon as it is available and at the same time it is <br /> providedIto N or my E(PLEASEPR k / IL <br /> APPLICANT NAME(PLEASE PRINT) l0/1/"'1���� (�I- SIGNATURE <br /> TITLETAX ID# <br /> pr`i ec�f L7�1 f,' <br /> Approved By l/ Dele Accounting Office Processing Completed By Date <br /> SITEMITIG.ATION AMOUNTPAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WnORpN/PLAN PE <br /> FEE:$ sl_Ya\ 41Yr� <br />