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SAN RUIN COUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFRS' GREEN FORM <br /> /o�o/r2 /y�` , ' I'�//�� �'v/f�_y SITE MITIGATION & LOP <br /> SHADED a9 OR EHD ONLY OWNER IDS UW UVr r,-J CASES`�G-... UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: ONEORIF OWER is CURRERTLYOR ALE WITH END <br /> PROPERTYGWNERNAME /0G / 4,TtAe,. (w4)993-37$9 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNERHOMEADDRESB �.r /O � /�P� �,f • <br /> CITY5?JC 4da.., C STATE zip / <br /> �J2US <br /> OWNER MAILING ADDRESS Po ��aX 5379 <br /> MAILINGADDRESSCITY STATE LP <br /> stvclIqq� fo.. <f-A 9sws <br /> ❑CORPORATION pO INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSISLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT-"QIUNTA CEA111, <br /> WATER QUALITY _ HW PIPELINE INVESTIGATION LOP _ <br /> FACILITY 10 IS INV# AnnmmpTl NEDEMPLOYEE LEAD AGENCY:EHD RWQCB-DTSC EPA_ <br /> T06o7?aZ -2< C)J R �oHNlvy <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PR ECT 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 S/COPE OF WORK"? ,Lr 1 YES NO ❑ <br /> BUSINESSIFACILRYISITEIPROJEOT NAME <br /> SITE ADDRESS I PROJECT LOCATION /S /)d SUITE# BUSINESS PHONE <br /> /oFYB <br /> CITY `. STATE ZIP <br /> �.�0 <br /> 54.� Cfl 93'1 o2 <br /> BOARD OF SUPERVISOR DISTRIOT LOCATION CODE / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTOONAL) <br /> MAILING ADDRESS CITY STATE LP <br /> SIC CODE APN# COMMENT: <br /> sTHIR /03- /(v- 0-5- <br /> THIRD <br /> D PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) <br /> IF <br /> rA4 SouicG Ve4 �c• / / <br /> A•� J !7 Cf3o 2�1-Y1.uu <br /> MAILING ADDRESS 9yy NG(OUa•�ME ,C� �4/j� <br /> Cm, / ,r STATE ZIP <br /> G.rsv C/a//t 44 9s9y9 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the()wner,Operator,AutlmriZed Agent,or RavloAnrib/e Party and I acknowledge that all PERMIT F£ES, <br /> PENALT/ET,EN£ORC'EM£NTCRARcES and/or lfouuy CIIARGE.0 associated with this project will be billed to me at the address identified above as the ACCOONTADDRESIS for this site. I also certify that all <br /> information provided on this application is true and correct:and that AS regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CCDES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operator,ARlbori o/Agent,or Responsible Parry for the project located above under facility/situ address,1 <br /> hereby Nuthoriae the release of any and all..In,reports,and other environmental assessment infarou fion to SAS 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) ��M �/ „ SIGNATURE <br /> TITLE Sia{{' ^VcrG�'r<"s'� TAXID# 77-Oy669SY <br /> APPROVED BY DATE ACCOUHnNO OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIOATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVE08Y WORK PLLA`N PE <br /> FEE:$ /! / y <br />