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San Juin County Environmental Healtt&epartrnent <br /> DATE MTER FILE RECORD INFORMATION ` FR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER ID#Bv 1 ����—., CASE UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER INFoRmATIONe CHECKiF OWNER CURRENTLYON/FILE <br /> WWITH EHD El <br /> PROPERTY OWNER NAME , I (&� q& <br /> First MI Last PHONE NUMBER <br /> BUSINEs NA E-MAIL ADDRESS <br /> Owner Home Ad ress <br /> X09 . 26 <br /> city sTq;E 4'4— zIP <br /> Owne.?%n ddress� <br /> lam' � Gt1 <br /> Mailing Address City S to zip <br /> S466k to ev at S <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIPA FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# - ACCOUNT ID PR#/ # ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB DTSC_EPA <br /> D oda o i3 S loa-1 <br /> FACILITY FILE COMPLETE THE FOLLOWING BUSINESS I FACILITY/SITE INFORMATION: <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESS/FACILITY/SITE NAME <br /> SITE ADDRESS SUITE# BUSINESS PHONE <br /> CIN STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifD/FFERENTfrom Facility Address Attention:or Care Of(optional) <br /> Mailing Address City STATE zip <br /> SIC CODE APN# COMMENT: <br /> THIR®PANTY 131LLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> (flailing Address PHONE <br /> CIN STATE zip <br /> ACCOUNTADDRESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Ap , erdfy that 1 am the Owner,Operator,or Authorized Ageni of this Business,and It acknowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HouRLYCHARGES associated with this operation 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 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 environmental 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. I &4, <br /> APPLICANT NAME(PLEASE PRINT) K:1',C*W\ 1IU� k JA SIGNATURE <br /> TAX ID Q <br /> TITLE b( ��2 _or1G�l�( • <br /> Approved By Date Accounting Office Processing Completed By V Date it T3 <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVE!a=--] <br /> FEE: <br />