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,Sar,duin County Environmental Health i artment <br /> QATEMASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> �16�i�1 J SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID# CASE# UNIT IV <br /> OWNER RI LE:Comm,rE rwFOLLOW/NG PROPERTY OWNER INFoRMATIoN: CmEvoftF OWNER CvRREffnroMFltEn7yN E H D <br /> PROPERTYOWNERNAME f/14 Garr-<a <br /> VVVV First M1 Lasf PHONENUMB£R <br /> BUSINESS NAME C _ - - E-MAIL ADDRESS <br /> [+n <br /> Owner Home Address <br /> 17 S if torr S <br /> City fio c a�+ C srA TIP 152,46 <br /> Owner Mailing Address <br /> Halling Address City State Zip <br /> .t. <br /> CORPORATION INDIVIDUAL0. . PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MmeA71GN_ENvIRONMf NTAL AssEss mEwr_VOLUNTARY CLEANUP_WATER QUALITY_MW PIPELJNE INVEBTIDATioN_LOP +� <br /> FACILITY ID# INV# AccouNT ID RJW1 RO# ASSIGNED EMPLOYEE LEAD AGENCv:EHD_RWQCB_DTSC_EPA_ <br /> �W03133$ 15 Z 1 15.1 <br /> FACILITY FILE COMPLETETHEFOLLOm/NG BUSINESS/FACILITY/SITE INFoRmwloN: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT?. YES ❑ No <br /> Is this an Emma Business LOcATtON but a NEW TYPE of regulated Business? yes ❑ No ON <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS ��D �' SUITE# BUSINESS PHONE <br /> e;'n n e 57�. <br /> CITY f STATE ZIP <br /> 9.5 2-02 <br /> t <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY4 KEY2 <br /> f Mailing Address IfD1FFERENrfrvm FaaV4yAddrass Attention:orCare Of(opVanal) <br /> Mailing Address City STATE TIP <br /> SICCODE APH# AIA <br /> COMMENT. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above: <br /> BUSINESS NAME r l rr r JJ ) _ Attention:orCare Of(opbbmt) <br /> Meiling Address Q Q Q/fs 2a�l)53 Z-0 3G (- <br /> cnY Sa n 4 r a G( 1,5316) STATE TIP <br /> AfaauuATAnogm for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> Blt.t.ING ATID CO\IPLLAN'CE ACK,-40WLEDCSIEYT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Aathnri.ed Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PFIVALrms,ENFOReEMEATCHARGES and/or HOURLY CHARGFS associated with this operation will be billed tome at the address identified above as the AccouMAnnxFss for this site. I also certify 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 SAS JOAQtnN Coiwrl'Ordinance Codes andlor <br /> Standards and 57ATr.and/or FEDERAL.Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY F.NVIR0NP1ENTAL HEALTH DEPARTMENT a oon a it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) / /f1 � � SIGNATURE <br /> TITLE � t ) TAX ID# 9 ! -~ 9 D Lr O y1/b.(1:��P�•fi�-SP./'lli<e5 /k.�U.�t�� 1 5p1 t <br /> Approved B Date Accounting Office Processing Completed By - Date Lk 1 -7 1 <br /> SITE MITIGATION AMOUNT PAIDDATE OF PAYMENT PAYMENT TYPE RECEIPT N CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:$ 3 Sv <br />