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San ,,,,Aquin County Environmental Health *artment <br /> DATE 0 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADEDAffMFOREH U4EQftkY OWNER ID# CABE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY/NFoRMATiom CHECK IF OWNER CURRENTLYON FILE WITH EHD <br /> PROPERTY OWNER NAME 6.Af— 1 4&4 / \ <br /> First MI I—Last \PHONE/NUM13ER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> Z c, A-42. <br /> city STATE_ ZIP S ZO <br /> S+DGv--j-OV1 l/�rLrL <br /> Owneraliln�ddr <br /> U2 <br /> Mailing s PityStat IIP <br /> Kl v <br /> F-o <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT._VOLUNTARY CLEANUP WATER QUALITY_ _HW PIPELINE INVESTIGATION _LOP <br /> FACILITY IO# INV# ACCOUNT ID PR#I RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCS_DTSC_EPA- <br /> IL <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT/NFORMAT/om- <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 /> BUSINESS/FACILITY/SITFJPROJECT NAME <br /> SITE ADDRESS I PROJECT LOCATION SUITE# BUSINESS PHONE <br /> k'z& �"h 91-4j. <br /> CnY JTU G1�n Y\ STA LP�5 zO� <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Melling Address 11D/FFERENTIrom Facility Address Attention:orCare Of(optional) <br /> toPF60,c) CeylFer Dr. Su► IGS- g- P <br /> IingLC'V1 ) C(-reSTA7E ZIPa'VC� <br /> SIC CODE YY l` APN NO COMMENT: J <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Responsible Party identified above. <br /> BUSINESS NAME l U bV61 V1PSS el� OIl A ntion:orCare Of (optional) <br /> ISSS D e <br /> t <br /> Melling Address PHONE <br /> Z4C)0I LJ S S. <br /> CITY STAT ZIP <br /> ccwsm <br /> / 0M <br /> ACCOLArrAppAgm for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMEN'IL: 1,the undersigned Applicant,certify that I am the Owner,Operator,Authorized.4gent,or Responsible Party and I acknowledge that all Pt.'H.SI1T FEES, <br /> PFVALTIES,ENFORCEMENT C11.4R(PES and/or Hot Rt.ICHARGES associated with this project will be billed to me at the address identified above as the ACCOUNTADDRESS for this site. I also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and S'TATF,and/or Feut_R.u.Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facility/site address,1 <br /> hereby authorize the release of any and all results,reports,and other emironmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> is available and at the same time it is provided to me or my representative. l r �( <br /> APPLICANT NAME(PLEASE PRINT) ?)�l Ro LVA- SIGNATURE / }{T( C\- <br /> / <br /> TITLE /! ,,„�j v - TAX ID# <br /> Approved ey Date I Accounting ORloe Processing Completed By Date <br /> $ITE MITIGATION DATE OF PAYMENT PAYMENT TYPE CHECK# RECEIVED BY [� K PLAN PE <br /> FEE:S AMOUNT PAID _-- —___ — _11��# __�. <br />