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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 11 11 SITE MITIGATION&LOP <br /> SHADWAREAS FOREHDOSEONLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTYOWNER INFORMATION: CHEDKIF OWNER CORReurtrou FILE WITH EHD� <br /> PROPERTYOWNERNAME / 1 <br /> Fiat MI Last PHONE/NUMBER <br /> BUSINESSNAME E•MAILADDRESS <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City Siete Zip <br /> CORPORATION❑ INDIVIDUAL[I PARTNERSHIP El FEDAGENCY❑ OTHER❑ <br /> SITE MITI GAT10N_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACIUTYID# INv# AccouxT lD Pq#IRO# °IT MOM-/, R gtEHDF'`+ R�Ll B :OTSCt4 .F�,s 'y"i <br /> *7� -.c mar.'T` .l:j#{�r',.rt.3'(r? ;:tkrt "rti.� 8� <br /> FACILITYFILE COMPLETETHEFOLLOWNGBUSINESSIFACILITY ISITE INFORMATION. <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an EXISTING BDslnew LOCATION but a NEW TYPE of regulated Business? YES ❑ NO ❑ <br /> BUSINESs/FAc1ure/Sire NAME <br /> Sm ADDRESS SURE# BUSINESS PHONE <br /> Cm STATE ZIP <br /> BOAND OF SUPERVISOR DISTRICT LOCARDN CUDE KEY7 - KEY2 <br /> Mailing Address ifOIFFERENTIlam FacARyAddeess Attention:orCere Of(optional) <br /> Mailing Address City STATE ZIP <br /> SICOODE AEN# ClaiAxExr; <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator identified above. <br /> BUSINESS NAME Attention;orCere Of (opBoml� <br /> Mailing Address PHONE <br /> CIiv, STATE ZIP <br /> Accouureil forfees end charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLInNee AL OWLEDGMLNT: 1,the undersigned Applicant,certify that I am the Owner,Operates,or Authorized Agent offish Business,and 1 acknowledge that all PertnnrFEos, <br /> FENALTzEs,ENFORCeszaATC/LIRGES and/or ROURLPCRARCES associated with ties operation will be billed tome at the address Identified above as theACCODNFADDRext for this site. I also certify that all <br /> information provided on this application is true and correct,and that all regulated acfividC$will be performed in accordance with all applicable SAN JOAQUIN CouNTY Ordinance Cotler and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at We above faulty/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 some as it Is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAX ID# <br /> Approved By Oats Accounting Once Processing Completed By Data RNs <br /> SITEMITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT CHECK# RECENED BY W QLµYyam,}•. <br /> FEE: <br />