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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATES �(o �37[ MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHAPED AREAS FOR EHD USE ON]- OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK OWNER IS CURBEwr <br /> ENn rONFfLrit END <br /> PROPERTY OWNER NAME P/OlagiS ` OL' Vila /Oki (109) 833538 <br /> if <br /> PRSi MI LAST PHONE NUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> SCP-scc2 u� above <br /> OWNER HOME ADDRESS <br /> !?ZS � l�esf �oorlrtrEr�e ��� <br /> DRY STATE <br /> zip 7 7 <br /> OWNER MAILING ADDRESS <br /> MAILING ADDRESS CITY STATE ZIP <br /> yy CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY ID If INV# ACCOUNT= ASSIGNED EMPLOYEE LE AD AGENCY:EHD_Y RWQCS_OTSC_EPA_ <br /> .JvH; <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES DO No ❑ <br /> IS THIS AN UISTING PROJECT LOCATION,BUTA NEWSCOPE OF WORK? YES ❑ No <br /> BUSINESS/FACILITY/SITE/PROJECT NAME he /, Y/x /`(T`O u <br /> efn vctLL o"e C <br /> SREAODRESSf PROJEqT <br /> CJ, u gZ1S SO LOCATION $URE# BUSINESS PHONE <br /> / ( Q ^q/ 7 <br /> CITY jV'CGL ^ CA ZIP /5377 <br /> 7 <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEYi KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS !� ATTENTION:OSCARS OF(OPTIONAL) <br /> 2-`7G 12 2- <br /> MAILING <br /> MAILING ADDRESS CRY STA IF <br /> Sri. �LGLt(YF7 <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAMEs <br /> U Y n I.1 5 r f �n rL�� V' A- TTENTION' ArPLf(E/Jf OPT/ LJ A I i <br /> MAILING ADDRESSPHD <br /> �// <br /> ;2-"(-3 o Cv-Gsc61� $wrT� !� �- Zz yjg_GS[ � <br /> CITY 5-&4,1 p�MA� STATE rI n ZIP <br /> ACCOUNTADORESS TO SEND FEES AND CHARGES: OWNERI] FACILITY/BUSINESS❑ THIRD PARTY/BILLIINNGq( <br /> BII.I.I\C AND COMPI IA\CE Ar:KVO%VTF.DCMF.NT: L the Imdenigaed Applicant,eerllfy Ilam I Alli the/Truer,OpconsOr.Asalearked,lifeNn,or Responsible PPrl,and I ackno virdge that all PEMIllr Fs Fe, <br /> PENALTIES,ENFORO::IIEATOLiRGES and/or llnoau'CRIRGET associated nigh this pruji d vvill be billed evnm at ilia address identified above as the ACCOONrAODRI..cS for this rile. 1 also certify that all <br /> information provided on This applicalion is Iruc and carred;and Ilial all reguhded activities will be performed in aceardanec with all applicable SAN JOAULIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL.Laws and REGULATIONS. As the undersigned ONnu,Opermoq:latlmrised Agent,or Responsible Parry for the to located above under facility/site address,1 <br /> hereby Authorin the release of any and all reSulls,reports,and other environmental assessment information la SAN.IOAGEIN COCSTY EwIROSSRNTSL HEALTH UEPSNTNIESI'as soon as it is available <br /> and at die same lime it is provided to me or my represented, I <br /> APPLICANT NAME(PLEASE PRINT) j `{T Mr /IS;'') <br /> SIGNATURE <br /> TITLE // O III VT - <br /> SCGUUr PV �erf' /u l QIn TAx iD# <br /> APPROVED BY DATE ACPAUNTINGOFFICEPROCESSINGCOMPLETEDW DATE <br /> SITEMITIGATION AMOUNT PAID GATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:¢37/_ 3�S C�HhPK 3w(,r Q ,v 2.45v <br />