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San Joanuin County Environmental Health Department <br /> DATE . I (, I I I MA. CER FILE RECORD INFORMATION "ha . R" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR END USE ONLY OWNER ID# CASE # UNIT IV <br /> v I <br /> OWNER FIMCOMPLETETHEFOLLOWNG PROPERTY OWNER /NFORMAT/ON.' CHECK/F OWNER CURRENTLPONF/LENom EHO � <br /> PROPERTYOWNERNAME <br /> Fist M/ Last W PHONE/ NUMBER <br /> BUSINESS NAME E+IAILAOORE9S <br /> S I o 541Q <br /> Owner Home Address AA nn <br /> I ed V1 14 gh <br /> City STATE LP A O <br /> LA <br /> Owner Mailing Address <br /> Melling Addrlres Clty ` Lon state rt Lp <br /> CORPORATION ❑ INDIVIDUAL PARTNERSHIP ❑ FEDAGENCY ❑ OTHER ❑ <br /> 817E MITIGATION ENVIRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP _ <br /> FACILIT/ ID # INV# ACCOUNTIO PRNRO # ASSIGNED EMPLOYEE LEAD AGENCY: EHD RWQCB_ DTSC _ EPA_ <br /> FACILITY FILE COMPLEIFETNEFOLLOWING BUSINESS / FACILITY / SITE INFORMA770AV <br /> Is this a NEW Business LOCA noN 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 ❑ NG <br /> BU91NENIFACIUWISITE NAME \ ( W n rS <br /> J 4 <br /> SITEAOORESS SURE # BU9IN BPHONE <br /> G O N , l rt a �. <br /> CITY ( � STATE LP <br /> BOAROOF SUPERVISOR DISTRICT LOCATIONCOOE KEY1 KEY2 <br /> Mailing Address KD/FFERENrhomFac11&Addresa Attention: wCare Of (optlonatf <br /> Meiling Address City STATE ZIP <br /> SICCODE APN # COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner of-Facility Operator identified above. <br /> BUSINESS NAME U r, I^ I 1 n Attention: orCare Of (Wma9 <br /> tAV1 V r <br /> Melling Address �^ PHONE got) L P 7e) C) <br /> CITY S G 1 STAt. LP ATW <br /> ACOOUNTAwRim for fees and charges 11 OWNER FACILITY/BUSINESS THIRD PARTYBILLING <br /> Bn.LING AND COMPLLINCE ACKNOWLEDGMENT: I, the undersigned Applicant, certify that I am the Owner, Operator, or Amhoriyed Agent of this Business, and I acknowledge that all PERMTT FEES, <br /> PEAR HES, ENFOECEsfENTCRARGFS and/or RGDKT.r Cf GES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRESs for this site. I also certtty that <br /> all information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SM JOAQm Cos Ordinance Codes and/or <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 authorize the release of <br /> any and all results and environmental assessment information to SAN IOAQUIN COUNTY ENVIRONMENTAL ID:AI.TR DEPARTMENT as soon as i available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME (PLEASE PRINT) G. a � ,qwp' SIGNATURE <br /> TITLEf� T DD # <br /> lit .t% V1`P � ✓ vd <br /> Approved By Date Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNTPAID OATEOFPAYMENT PAYMENT TYPE RECEIPT # CHECK # RECEIVED BY WORK PLAN PE <br /> FEE: $ <br />