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SAN QOUIN COUNTY ENVIRONMENTAL HEALTH OPARTMENT <br /> DATE11 LOWNERID0 <br /> ASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> - - SITE MITIGATION & LOP <br /> SIIAO e 0 EHD ONLY CASE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER IS CURRENTLY ON FILE WITHEHD � <br /> PROPERTYOWNERNAME P"16q;s COW, OY4 ISN (Zo9) 833-538 <br /> FIRST MI LAST PHONE NUMBER <br /> BUSINESS NAME EMAIL ADDRESS <br /> SC�fu2 uq q,lb[�V� <br /> OWNER HOME ADDRESS <br /> /72-8 1" !gest e-044-'kerce LJa <br /> CITY Trgc �G4 LPgs3j / I <br /> OWNER MAILING ADDRESS ! a,6O ve <br /> MAILINNGI ADDRESS CITY STATE LP <br /> X CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACIUTYID# INACCOUNTID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQCB_DTSC EPA_ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS ANEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES Dd No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES ❑ No 14 <br /> BUSINESSIFACILRY/SITEIPRWECT NAME rOu <br /> SITEADDRESSIPftOJE LOCATION _ <br /> O(T u SURE# BUSINESS PHONE <br /> Rd <br /> Cm STATE�YCLG > CA LP 95377 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> MAIl1NG ADDRESS CIttV�..�1 <br /> J STATE ZIP SV <br /> SIC CODE 11 APN# ComnBlr: C j <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME U a ,G� � <br /> � r ,e�I S �!'�!Qo r/ � A TTENTION AI(EPf <br /> I (/( 4 ?` <br /> MAILINGADDRESS <br /> PHONE, <br /> Cltt STATE C LP <br /> ACCOUNTADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS❑ THIRD PARTY BILLING„ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant,certify that 1 am the Owner,Operator,Ataborieed Agent,or Responsible Parry and 1 acknowledge that all Pt'RAUTFUEs, <br /> PL;nALTIES,ENFORCEAfENTCRANGES and/or HOURLY CHARGES associated with this project will be billed tome at the address identified above as the ACCOUNTADOR£Se for this site. I also certify that all <br /> information provided on this application is We and correct'and that all regulated activities will be performed in accordance with all applicable SAN JOAONN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Owner,Operamn Authored Agen(,or RHponsible Party for the project heated above under facility/site address.I <br /> hereby authorize 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 same time it is provided to me or my representative. / !� <br /> APPLICANT NAME(PLEASE PRINT) /lY/� McL�?,ral�111,/8Wool SIGNATURE �i-• Y✓T /••C 'f ` <br /> TITLE <br /> /Set7,ror ✓ FGf TVG Qr/Y TAK ID# �'�r�VVV''f✓✓✓/LLLL�yyy'�11VVy / <br /> APPROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE: <br />