Laserfiche WebLink
San aodquin County Environmental Health Del artment <br /> DATE / <br /> �j�tin O P I MASTER FILE RECORD INFORMATION Ea FRTt GREEN FORM <br /> SITE MITIGATION 81 LOP <br /> aHApen" FmigH121,119ONLY OWNEA1D# cA9E# o UNIT IV <br /> OWNER FILE:CavmErE 7HEFotLOwNe PROPERTY OWNER INFORMA770N.' M'OWNER NnroMnL£IarN EHD� <br /> PIaPBnYOWIBiN 4M <br /> First M/ Last PHoNENUIIEII I lills.%W16.1 IS 1.11A.0 <br /> BUlN®s Nass `tJ C WtAEafAAAgaiwss FEB 0 6 2012 <br /> Owner Banta Acidness <br /> 17m,, tWoofto :AQvir ox. 9700 . L R <br /> CRY STATe LPPERM ERVICES <br /> ,1`53 <br /> Owner Meiling Address <br /> F <br /> Mailing Address CNy, Slate Zip <br /> CoRPORATaN❑ INpNDUAL❑ PARTNERSHIP❑ Fm Asaimm❑ DTNEA❑ <br /> SITE MITIGATION_ENVIRONMENTAL AYE{EMWT A&VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILRYID# INN# Acccow ID I liFlIfRO# ASSIGNED EMPLOYEE LEADAGENCY:EHD RWOCB_DTSC_EPA_ <br /> oa37L-l' 1 C715 k <br /> FACILITYFILE COMPLETETHEFouowtee BUSINESS/FACILITY/SITE tNFORMAT/oN: <br /> Is this a NEW Business LOCATION fat previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No J9 <br /> Is this an EYJSTING Business LOCATION but a NEW TYPE of regulated Business? YES JR No ❑ <br /> BUSHIEss/FAcllm/SDE Naas: U <br /> SITE ADDRESS /6470 SURE# BUSINESS PHONE <br /> .C.l c y'Yzl <br /> Can, L4711,zee Er X5730 <br /> BO/wD OF BtiPEAY1$DR DISTRICT LocAnDte CooE KEH KEY2 <br /> MaIIi g Addanan HO/FFERENTean FacARyAddieae Attention:wCare Of toPaanag <br /> C A -r4:; t"w IOC ZeiU -/> - <br /> Mailirg Aridness City PNSTATE P Y n <br /> SIC CODE A # COMMEM: t::j <br /> C <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacilfty Operator identified above. <br /> BUSINESS NAME [ V1,' Attention:orCare Of fapaisW <br /> Mailing Address 33 N7o 3�,,,, t r PHONE ems^ -0 <br /> rqff <br /> Cm PrMEN� , LP o <br /> Aiaa 2BGDBFffi for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMITM ACKNOWLEDGMENT: I,the undersigned Applicant,certify that 1 Am the Owner,Operator,or Authort¢ed Agent of this Business,and I seclmow ge that all PERMIT FEES, <br /> PENALD£S,ENFORC£M£M CHtAGES and/or ROORLY CHARGES associated with this operation will be billed to me At the address Ideudfled above as the A( OI'NTAODRESS far this site. 1 AM eerdfy that <br /> all information provided on this apput.tim,is true and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COI'NTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property lorated at the above facility/site address,1 hereby authorize the release of <br /> ens and all results and environmemal assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME. "as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT N/A�MEE((PEEASE Pater) /l/lry Pj( -F,5' C01Aj,f5 OG 1 SIGNATURE t7s <br /> TITLE a Pn�i/moi -U s+1�> uf"r,rPl ' TAX ID#�,0���7f/� <br /> Approved ay oats Acocti g Once Processing O Plated By <br /> am MITIGATION I AMDUteTPAID DATEm PAYMENT PAYMENT T folut PUN PE <br /> FEE:II <br /> J 'zs v /oSrb9 t <br /> is �7 f <br /> !v pact <br />