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• ,,i EC <br /> 9168610430 07/08/"" 15:08 <br /> 1 4111� JUL 0 9 2013 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE ?/g�/3 MASTER FILE RECORD INFORMATION"MFR" 4MWMMENTAL <br /> �/ /t � SIT 'ap�i'b.OPNfc�IT <br /> SHADEDAILAa FOR END UdE ONLY OWNER IDM CASE# .yr�LJ 1 7e��� US,]'T IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: 0HECKff0WNkW1$CURREWLYONNLE WrH EHD <br /> PROPERTY OWNER NAME <br /> F1R57 M, LAST PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME ..r <br /> r7 <br /> OWNER HDMEADDRESS <br /> Cm STATE TIP <br /> OWNERMAuNpADDRESS 70. <br /> ISOX 7/1 <br /> r1 <br /> MAIUNG ADDRESS CITY D� STAT ziptr 7"5ao4/-070 <br /> ORATION/ ❑INDIVIDUAL ❑PARTNERSHIP ❑GOYERNMENTAGENDY El RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION✓ENVIRONMENTAL ASSESSMENT W...VOLUNTARY CLEANUP WATER QUALITY HW PIPELINE INVESTIGATION_.LOP <br /> FACILITY IDS INV# ACCOUNT ID PR#/RO# -ASSIGND.EtaPLOYEE� LEAD AtIENOY EHD Fa<WQCp OT80 -CEPA <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THISANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 0No 9-'IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES Its No ❑ <br /> BUSINESS/FACILITYISITFJPROJECT NAME -7'L l 1 <br /> SITE ADDRESS/PROJECT LOOATION k SUITE# BUSINESSPHONE <br /> x, u As Ll.�c "1&IA L ' <br /> Cffy STATE ZI► <br /> BOARD Or SUPERVISOR DISTRICT.. LOCATION CODE KEr1 KE'Y2 . <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OW77DN41.) <br /> MAILING ADDRESS CITY STATE ZIP <br /> SIC CODE . <br /> APN M COMMENT <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> SUSINESISNAME /'�/� ��G /` C / ATTEN ION: CARE OF(OPT/ONALJ <br /> e v T! J <br /> N'AILING ADDRESS 3017 !o j PHONE <br /> Cm I. STATE ZIP <br /> G A- 43 SZ,,-70 <br /> AOCOUNT ADDRE89 TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUS[NESSE] THIRD PARTY BILUNG8 <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that Ism the Owner,OperaAir,Authorized Agee,or Responsible Pang and I acknowledge that all Pmmir FEES, <br /> PENAL77ES,ENFORCEMENT CHARGES and/or IIDURLYCHARGE.S associated with this project will be billed to nue at the address identified above as the ACCOUNTADDRESS for this site. I Also certify that 1111 <br /> information provided on this application is true and correw..and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL laws and REGULATIONS.As the undersigned Onaier,Operator,Aulhnrized Agen,orRe+parslble PartJh for the project located above under facility/site 11ddress,I <br /> hereby authorize the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN CO ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided to \or my representative. <br /> APAN <br /> PLICT NAME(PLEASE PRINT) ZJ�i f-�J � ��v}a�)l Gj SIGNAYURE ' <br /> TITLE �� �, e,. S n f�c .! f _�f�f✓,�(/J �TAX IDM J <br /> AROVED BY DATE ACCOUNTING OFFICE PROOESSMG PLETED BY / %i— DATE <br /> PP <br /> SITC MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# % <br /> j <br /> CHECK# REOEIVBD BY }YllGflitf'tJutPE, <br /> FEE: - - <br />