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• !• ; SAN•QUIN COUNTY ENVIRONMENTAL HEALTH•ARTMENT <br /> a » GREEN FORM <br /> DATE S �� !3 MASTER FILE RECORD INFORMATION MFR SITE MITIGATION& LOP <br /> SHADED END USE ONLY OWNER IDM <br /> CASE# UNIT IV <br /> CHECK IF OWNERS CURRENTL Y ON FILE WITH EH El <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: <br /> PROPERTYOWNERNAME P✓O /6q;5 Cos, O✓Q Y O J4 (to?) 533-`7 38 <br /> - —1-.4 ^- M/ L43i PHONENUMBER <br /> I FIRSTE-MAILADDRESS <br /> BUSINESS NAME S�.�cf•� u4V <br /> 101'4 <br /> OWNER HOME ADDRESS ,7'L8 (� �a('�y /r��e*Aer(°e w74 <br /> CITY -re Cot C 7 <br /> OWNER MAILING ADDRESS -oS^T Q— r// / "Ove <br /> Ove <br /> STATE LP <br /> MAILING ADDRESS CITY <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENTAGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IC <br /> INv# ACCOUNT ID PR#/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_DISC_EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES 04 No ❑ <br /> ISTHIS AN EXISTING PROJECT LOCATION,BUTA NEW SCOPE OF WORK? YES ❑ No x <br /> BUSINESSIFACILITY/SITE/PRWECT NAME I V /a✓O u LL 0-ie r <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS/PROJECT LOCATION 5-D l N <br /> / U' u d J L <br /> STATE ZIP ?5'377`3 7 7 <br /> Dirt FYcc� GA <br /> BOARD OF SUPERVISOR DISTRICT <br /> LOCATION CODE KEV1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROMFACILITY ADDRESS - ATTENTION:ORCARE OF(OPTIONAL) <br /> 25< v ,'/.�o ,esti S Z z til f:l' L 1 in <br /> STATE ZIP <br /> MAILING ADDRESS CITU <br /> [FIC J APN# ' f COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> S��-//-��."�� O�W/ ,��'^{c,�/ u).,s,1.. T~K_/!"r✓'sis�/'I1 <br /> TTENTON AIEZpS OPT <br /> BUSINESS NAME LVUQ IK UMAPHONEf <br /> MAILING ADDRESS / � $TATE1 T( zip <br /> ��(//l•/© <br /> CITY <br /> !rn <br /> A'cc r <br /> SENO FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRDPA - <br /> 'COMP uNCE ACKNOWL¢DGMENT: 1,the undersigned Applicant,ecrtify that 1 am the Owneq Ope.,vr,Anlboriyed Agent'or Respmrsible Parry and I acknowledge that all <br /> 5,EA'FORCEMEAT CHARGES antler HOURLY CHARGES associated with this Project will be billed to me at the address identified above as the AccouWADDRESS for this site. 1 also certify <br /> motion provided on this application is true and correct;end that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/0 <br /> STANDARDS and STATE antler FEDERAL Laws and REGULATIONS. As the undersigned OlvneG Operator,Amhorized Agent,or Responsible Party far the project located above under facility/site address,I <br /> hereby aatharice the release of any and all results,reports,and Other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT aS Soon as it IS available <br /> and at the some time it is provided(o me or my representative. I � SIGNATURE r <br /> APPLICANT NAME(PLEASE PRINT) l t M EWO Y/ <br /> TITLE O/• �QV- �V pGAr TAx ID# D� <br /> V T/✓VT 1. ����VV C. 1O <br /> 44 <br /> P <br /> $ITE MITIGATION AMOUNT PAID DATE OF PAYMENT"' PAYMERfTVPE R@CEIPT# - CNECN# RECEIVED BY WORN PLAN PE <br /> FEE: <br />