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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEI..Q�'j_ MASTER FILE RECORD INFORMATION MFR <br /> " GREEN FORM <br /> 11 SITE MITIGATION&LOP <br /> SHADED AREAS EOR EHDUAE ONLY OWNER ID# CASES UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIB <br /> LE <br /> PAARTY INFORMATION; CHE/CKIF\OWNERI9CURRENTLYONF/LEN9TN EMO <br /> PROPERTY OWNER NAME • V atcv S <br /> FIRST Ml LIsT PHONE NUMBER <br /> BUSINESS NAME � n ^ E-MAIL ADDRESS <br /> OWNER HOMEADDRESS <br /> Cm S ZIP <br /> OWNER MAILING ADORERS <br /> MAILINOADDRE66 CITY STATE ZIP <br /> ❑CORPORATIONINDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY C)RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY I D# INV# AcrouNTID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DiSC_EPA_ <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,BUTA NEW SCOPE OF WORK? YES ❑ No <br /> Bub IF LITY1EIPROJE T N E <br /> SuMIPROJEqTLO ION SUITE# BUSINESSPHONE <br /> CT� STATE ZIQ"]S:it <br /> AP <br /> Ma, <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 ""F1 <br /> MAILING ADDRESS.IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAILINOADDRE$s CITY STATE ZIP <br /> SICCODE APN# w 0 COMMENT: <br /> w .iL <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> USINESS ME rtet ; ATTENTION:ORCARE OF OPr/Oy L � <br /> ON /�� <br /> STATE �P n <br /> ACCOUNTADDRESSToSENDFEESAND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING' <br /> 13[LLI`1G Ac0(7OITPLIANCE AC"DWLEDC\LEST: 1,the undersigned Applicant,certify that I am the Owner,Operarar,.4whoriyedAgem.or Respaasible Porn-and I acknowledge that all PERS FEES. <br /> PEAALTTES.E,N'FORCE.IIEATCH.IRC.FS nndlor 110URI.T CH.IRGES associated with this project will be billed to me at the address identified above as the ACCOVATADDRESS far this site. I also certify[hat all <br /> Information provided an this application is true And correct:nml that all regulated activities%vill be performed is accordance with all applicable SAS JOAQUIN COUN7V ORDINANCE CODES nndlor <br /> SIA,NuARDS and SfAIE and/or FEnvRAL Laws and REGULATIONS.As the undersigned Owner,Operator,AufboriyedAgarr,or Reepoasib/e Parry for the project located above under faeillty/site address,I <br /> hereby authorize the release of any and all results,reports,and other environmental nssessmeat information to SAN JOAQUIN COUNTY is R01111fEINTAL IVALkH DEPART1fEN'f ns sooti as It is Available <br /> and at the same time itis provided to mAe or my representative. ^'n,n <br /> Wks( <br /> APPLICANT NAME(PLEASE PRINT)\ �Il -ZVV . t-.OVGM SIGNATURE <br /> TmEr-w A�11���• G� J1�\ 'b1� TAX 101E <br /> APPROVED BY DATE ACCOUNTING OFFIDE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENTJ PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE_ <br />