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SAN JOIN COUNTY ENVIRONMENTAL HEALTH C 'ARTMENT <br /> u GREEN FORM <br /> DATE �<<I_I MASTER FILE RECORD INFORMATION MFR <br /> T SITE MITIGATION& LOP <br /> ED ARFJIS FOR END U8E S7HLY OWNER ID*_` - - CASE# UNIT �V <br /> SHAD <br /> q (pCHE <br /> OWNER FILIr:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATIO CKIFOWNER ISCURRENTLYONFILEWITH END/� <br /> PROPERTY OWNER NAME l4"-f 1�.f r V 6 ~ fW+' <br /> FIRST MI LAST PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME f - <br /> vL FYI Q n �-. -+—n.. [57-tri.-!rt !y' Cd.(" o 'R 7-fn-17 - <br /> OWNER HOME ADDRESS / <br /> CITY STATE LP <br /> OWNER MAILING ADDRESS <br /> �l 7 <br /> MAILING ADDRESS clrr STcC to STATE 7J <br /> P�.5�-O�, <br /> ,CORPORATION ❑INDIVIDUAL .❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP X <br /> FACILITY ID# INV# ACCOUNT ID- PR#! O# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC EPA 11 a <br /> q 33 (`1� 4.*4'WN'.j <br /> FACILITY FILE:COMPLETE BUSINESS!SITEI PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO CTt] <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES [> NO ❑ <br /> BUS1NESSIFAcwTYISITEIPR0JECT NAME (� I <br /> f SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> cmr ,STI)G 4 fia,, C ZIP15Z-0 Z <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE: KEY1 KEY2Li <br /> 1 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILRY ADDRESS ATTENTION:ORCARE OF{OPTIONAL) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE API t#32- 170`r''O ',;{ COMMENT: - f. <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAMEr r ATTENTION:OR CARE OF(OPTIONAL): r <br /> Onj0r t Jr -r4 �nn n `G t1l Co <br /> MAILINGADDRESS.g PONE <br /> Pa F>^��1L isT re 2 Z3�1-asks <br /> CITY 57LO�.�" 1 .tel (.._STATE zip <br /> ' <br /> ACCOUNT ADDRESS TO SEND FEES AND C14ARGES: OWNER[] FACILITYIBUSINESS❑ THIRD PARTY BILLING <br /> i <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent,or Responale Parry and I acknowledge that all PEIUHTFEES, <br /> PENALTIES,ENFORCEMENT CIIARGES andlor HOURLY CHARGES associated with this project will be billed to me at the address identified above as the ACCOUNT ADDRESS for this site. 1 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 JOAQUIN COUNTY ORDINANCE CODES andlor <br /> STANDARDS and STATE andlor FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Audiarized Agent,or Responsible Party for the project located above under facility/site address,l <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) <br /> SIGNATURtce,�� <br /> TAXIDft <br /> APPROVEDBY DATE ACCOUNTING OFFICE PROCES81NO COMPLETED BY DATE E�PLAmPE <br /> SITE MITIf'�T'^"! P�^���T pato DA7E OF PAYMENT PAYMENT TYPE RECEIPT II CHECK#t RECEIVED BY WOFEE:S <br />