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REGtivty <br /> Saquin County Environmental Heal#FIR$' <br /> partment <br /> DATE *ASTER FILE RECORD INFORMATION I i12 4 MEN FORM <br /> Z `n^ <br /> SHADEDAREASFOR EHOUSEONLY /SE <br /> OWNER ID# CASE6d����4 ENVIR NMENT �RivLOP <br /> 514-006SDOD PE MIT <br /> OWNER FILE-COMPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMAwiv: CHECN/F OWNER CUMENTLYONFaEWerREHD� <br /> PROPERWOWNERNAEIE1 <br /> U T V-� .v\ ( ) <br /> FM MI i Last PHONENUMBER <br /> BUSINESSNAME £-MAILADDRESS <br /> Owner Home Address <br /> CRY STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION[I INDIVIDUAL[] PARTNERSHIP El FEDAOENCY❑ OTHER❑ <br /> SITE MITIGATIoN_ENv1RONMCNTALASsmmeNT_VOLUNTARY CLCANUP_WATERQUALiTY_HWPIPCLINe INVEaTIGAflON LOPet:f <br /> FACILITY ID# INV# ACCOUNTID PR O# AssiONEDEMPLOYEE LEAD ADEN=EHD_RWQCB_DTSC_EPA_ <br /> 7z LISA /r. <br /> FACILITYFILE COMPLETE THEFOLLOW/NGBUSINESS IFACILITY/SITE/NFORMATtON' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No&r <br /> Is this an EXISTING Business LOCATION buts NEWTVPE of regulated Business? Yes El Noel� <br /> BUSINEss/FACILITY/SITE NAME <br /> S14eLim <br /> Sne AOOREss SUITE# BUSINESSPHONE <br /> CITY STATE ZIP <br /> �OCi N �iSZ�O <br /> BOAROOFSUPERVI:IORDIsTWCT LOCATIONCODE KEPT KEY2 <br /> Mailing Address NOIFFERENTtrowiFac/l/tyAdDruss Attention:orCare Of(oplfona/# <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BusiNESs NAME Attention:orCare Of(opftorra/J <br /> Mailing Address PHONE <br /> IJUL�t TR (Yp e ti Q-rwz to ylt. ssUAk K ao <br /> CITY STATE ZIP <br /> 'F��r� ca✓ �' CI <br /> AC_.COCNrAtnoaeae farfees and charges OWNER FACILITY/BUSINESS HIRDPARTYBILLING <br /> AM <br /> BILLING AND COSWLLWCEACXNO\YLEDGMENT: 1,the undersigned Applicant,cerlify that t am the Orvner,Operator,or An lunivad Agent of this Business,and nrlr nt TIN P£Rartr F£E5, <br /> PENALTIES,ENFORCPIIFMCHARGES and/or ROURL]'rHARG£S a55aflatCd with this operation will be billed to meet die address Identified apart m the ACCOLINTAUDRRSS for this Site. I also certify that <br /> all information provided on this application is Inle mid correct;and that all regulated activities will be performed In accordance with all applicable SAN JOAQUIN Cou Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and emironmmnal assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and At the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) (�tp /J „_ .,,r`LF� SIGNATURE <br /> TITLE <br /> TAX ID 1 <br /> ST�1�N �t�l C n}C.S�C <br /> Approved By Dab Accounting OmOe Prxasalne CRmplebd 8y <br /> SITE MITIGATION OUNTPAID DATE OFPAYMENT AYMENTTYP RECEIPT# CHECK# RECEIVEDBY WORTH P�L7ANP <br /> FEE:f �` ., <br /> D( k®r <br />