Laserfiche WebLink
SAN JOA^'lIN COUNTY ENVIRONMENTAL HEALTH DFpARTMENT <br /> DATE �tII_(� MA R FILE RECORD INFORMATION ��9 GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# _ UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHFCxlFOWIVERISCVRRENnyoNF1LE wyrH EHD ❑ <br /> PROPERTY OWNER NAME ) q 6 r <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME r E-MAIL ADDRESS <br /> oL I yl p/1 LI n e.S Trn.e-A *t t%-17 <br /> OWNER HOME ADDRESS <br /> CITY STATE Zip <br /> OWNER MAILING ADDRESS `y � Ce^-tel- S� <br /> MAILINDADDRESS CITY [ STATE LP <br /> Sr��G, fia� (514- . gff206 <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑REBPONSISLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR*1(O DO ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB DTSC_EPA <br /> 33 (J 22 �vl�~"� <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES NO ❑ <br /> BUSINEssfFACILITYISITEIPROJECT NAME pp <br /> 11 M 0.4 �Tr1 Ve5T'NI.e.-,7t' <br /> SITE ADDRESS I PROJECT LoCATIoN 73n��- ) ��, SUITE# BUSINESS PHONE <br /> tJ ll <br /> CITY STS `r fiQ n CA LP9za <br /> BOARD OF SUPERVISOR DISTRICT / LOCATION CODE / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL)- <br /> everl -I <br /> MAILINGAODRESSCITY STATE LP <br /> SIC CODE APN# COMMENT: <br /> 11 l - 170, Iv 11 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME r"p A + r Cir T 'le-�(n tiO fe- ATTENTION:ORCARE OF(OPTIONAL A r (� <br /> � �� <br /> MAILING ADDRESS(—� �^✓t ✓ We 5 r�. / LL1 Z,3 �Q(5113 <br /> 1J <br /> Gm S�-O G` fi0✓1 .. STATE Zip � <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER[] FACILITYI!BUSINESS❑ THIRD PARTY BILLIN G;K <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT. I,the undersigned Applicant,certify that I am the Owner,Operator,Authorized Agent'or.ResponsilVe Party and 1 aclmo"fedge that all PER,trrTFEES, <br /> PENAL7YEs.ENFORCEmEAI CHARGES andlor HOUJRL r CHARGES associated with this project"311 be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that aU <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance With all applicable SAN JOAQU FN COUNTY ORDINANCE CODES aodlor <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,Authorized Agen;or Responsible Parry for the project located above under facilitylsite address,l <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY Er'VIROlT1ENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to me or my representative. I <br /> APPLICANT NAME(PLEASE PRINT) Uj)) If,__-�Q d l� SIGNATURE <br /> S/ie/e�-/1455�---, <br /> T ,-,���C!'G�ct�Q jS 6wN �irS c f�Sen 1`��V�— TAXIDS <br /> APPROVED BY DATE AccovNTSmO OFFICE PROLESSINO COMPLETED BY DATE <br /> SITE MITUr'"ruw P+ ....,sur-Oslo DATE OF PAYMENT 1.PAYMENT T_YPE RECFJPT_# C+t7tECKI `yRECEIVED_BY WOR-�{j PLAN PrE- <br /> FEE:$ —! � SA � 1 — �—•-- � L�� L� <br />