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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> --- —__- SITE MITIGATION&LOP <br /> SHADED AP-40 P0(1_EItDUeEONLY OWNER ID# CASES UNIT 'V <br /> OWNER FILE:COMPLETEPROPERTY OWNER/RESPONSIBLE PARTY hvFoRw Tion; CHEOKIF OWNER CURREH7LY0HF1LEWITH EHD <br /> PROPERTY OWNER NAPE f)t=C--N A C—v\rl(J `/ — '—o <br /> First Mi Las( PHONE NUMBER <br /> BUSINESS NAME �^ ••'�� E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE zip <br /> i <br /> Owner Mailing Address _V,o <br /> Malting Address City �O <br /> state Zip <br /> Zip <br /> ❑CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY 0 RESPONSIBLE PARTY OTHER LL <br /> SITE MITIGATION--ENVIRONMENTAL ASSESSMENT 'VOLUNTARY CLEANUP_ —WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FacfiarvlDd INV# ACCOUNTID ��PRf OM AS NEDEMPLOYEE LEADAGENOY:EHD--LRWQCB. DTSC_ -EPA- <br /> 388 7 <br /> EPA_3887 351 <br /> FACILITY FILE: COMPLETE BUSINESS/SITE/PROJECT AfFORMAT/ow <br /> Is this a NEw Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES O No P< <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? \ YES JR No ❑ <br /> BUSINESS/FACILITYISITE/PROJECT NAME �Q�.�C�, L //•GL i V�/1 S <br /> SITE ADDRESS I PROJECT LOCATION (4,-7 �0.�7 `�` \ �� SUITE to BUSINESS PHONE <br /> N <br /> CISTATE ZIP <br /> BOARD OF SUPERVISOR DISTRICT y LOCATION CODE / KEY'I J�KEY2 - <br /> __ 1 <br /> Mailing Address R'DIFFERENT from FaclldyAddrese Attention:or Care Of(optiona)) <br /> Mailing Address City JC <br /> STATE ZIP n,5-?r - <br /> SIC CODE APN k COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Patty is different from Property Owner or Responsible Party identifredabove. <br /> BUSINESS NAME <br /> Cc)—,rci Y-,O 1--r- <br /> C, Attention:orCaro Of (opllonal) <br /> Mailing Address PHONE <br /> Lov-Q �r~l t�vL Sc3��2 Zo 57 -ZZzr <br /> C" t L� e, IC) STATE ZIP <br /> 7\ f535-� <br /> ACcoawrAiwREss for fees and charges OWNER FACILITY/BUSINESS <br /> LAIRD PARTY BILLING \ <br /> Uif.I,ING AND COSIPLIANCE ACKNoyn,p.DGAIENT: 1,the undersigned Applicoll,certify that f ann the(honer,Operator,Autliorited Agent,or Res/;ausible Party and I acknowledge tbal atl PER,vtrrLgv, <br /> PFAALl7ES,EN ORCEALFA7'(-TLIRCES nad/or lfOURLPCH.iRGES assoclsted with this project will be billed to me at file address Identified above as the A COIIATAI)pRESIS for this site. I also certify tbat all <br /> infonnalion provided on this application is Into and correct;and Ihal all regulated activilies will be perfurined in accordance with all applicable SAN JOAQUIN COUNrY Ordfuance Codes and/or <br /> Standards and Sr"E and/or FEDERAL Laws and Regulations, As the undersigned Owner,Opernfor,Authorized Agent,or Responsible Party for the project located above under facility/site address,I <br /> hereby authorize the release of any and all results,reports,said other enviramleufal assessmert inrarmatiun to SAN JOAQUIN COUNI'Y ENVIRONMENTAL FfEAL1H DEPARTMENT as soon as It <br /> is nenilnbte anti Al file same time it is provided tome or my rcpresenbntive, <br /> APPLICANT NAME(PLEASE PRINT) T 1,VA [AG�Se- SIGNATUR <br /> TITLE J tU YVO✓.lac` GJ�t CO1'-L)(- .tom TAX 0# <br /> "�`1 ' f (.- a3 Y',`tab <br /> Approved By Date Accounting OHloe,Processing Completed By <br /> onto <br /> SnE Mtr AT N AMOUNT PAID— DATE OF PAYMENT PAYMENT TYPE J <br /> RECEIPT to J�CHECKO RECEIVED DY�F WORK LAN PE <br />