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0 0 <br /> Sal, Joaquin County Environmental Health Department <br /> "MFR" GREENFORM <br /> DATE 3-193 MASTER FILE RECORD INFORMATION MFFd <br /> (_../I_ n SITE MITIGATION &LOP <br /> SHADE.Aft A9 F0 EHD USE ONLY OWNER ID# /D&91 CASE#Se(06`,7 ?— UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERT/OWNER INFORMATION.* CHECK IF OWNER CURRE,YrcromraewirH EHDE1 <br /> PROPF.RTYOWNERNAME D� G <br /> First MI Lest PHONE NUMBER Ze a <br /> E-MAIL ADDRESS <br /> BUSINESSNAME <br /> (Y M (i <br /> Owner ome Address �✓ �i�__ ^J _. <br /> City �. _ _ L/'// �Q STATE ZIP <br /> Owner Mailing Add se Y'v / <br /> �_ O <br /> Meiling Address City Zip <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP El FED AGENCY El OTHER <br /> SITE MITIGATION ZENvIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LDP <br /> FACILITYID# INv# ACCOUNTIO PR#/RO# As ON DEMPLOYEE LEAD AGENCY:END RWQCB_DTSC_EPA <br /> GSSG P 955& P D ossy6 <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACI LI /SITE ORMAT/ON: ,,��{{ <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ElNolff <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES i] NO>g <br /> BUSINESSIFACILITYISIrE NAME V ac rlv� <br /> V�1 ' <br /> SITEADDRESS 9 v� SUITE# BUSINESS PHONE <br /> CRY STATE ZIP <br /> BOAROOF SUPERVISOR DISTRICT l LOCATION CODE / KEYI KEY2 <br /> Mailing Add res a ifDIFFERENTfromFacllityAddress 1 Attention:orCare Of(opbDromi <br /> STATE ZIP <br /> Mailing Address City <br /> APN# <br /> SIC CODE COMMENT: <br /> rG3-our-y <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESSNAME enI5n:orCare OF,(ce, QCKs ea, / L <br /> Mailing Address I PHONE <br /> 3- VI rK STATE <br /> C" <br /> WeeleaG <br /> Arroi WAamm for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACBNOWLEMNIENT: 1,the undersigned Applicant,certify that I am the Ouner,Opernlor,or AudrorLed Agent of this Business,and 1 acknowledge that all PER.IIIT FEES, <br /> PEN:ItnES,[:TFORcalmd rCHARGes and/or 11OLmYCHARGes usnciated with this operation trill be billed to Ire at headdress identilied above as the ACCOL07 tDDRF6 for this site. 1 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 SAN JoAQNN CouNTV Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly located at the above facility/site add s,1 herebyauthorize the release of <br /> ane and all results and environmental assessmfo <br /> ent inrnmtion t.SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIEN"f as soon as i I arailable and nl the some Note it is <br /> provided to me or my representative. I/ �" <br /> APPLICANT NAME(PLEASE PRINT) ¢� js'�Q�_ l tI I SIGNATOR <br /> TAX IDii <br /> TITLE r.O e_Z) _ Q <br /> Approved By )els t Accounting Office Processing Completed By <br /> S <br /> ITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> :f <br />