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San .&Uin County Environmental Healtheartment <br /> DATE 1711 <br /> / MASTER FILE RECORD INFORMATION "MFR" J'60'16—GREEN FORM <br /> / SITE MITIGATION & LOP <br /> 6HADED AREAS EQ8 END USF ONLf OWNER ID# IDW OOV2-"� CASE# UNIT IV <br /> SRa�6 tied <br /> OWNER FILE:COMPL�ErE/THEFOLLOW/NGPROPERTY OWNER INFORMA TION.' CNetR/F OWNER CURRENTLYONFREWirN END <br /> PROPERTYOWNERNAME f�/y ,y�//I y�� / 5-O/ 5-1 <br /> First MI Last PHONENUkISER J <br /> BUSINESS NAME <br /> LN HMIL ADDRESS <br /> �a_/ El� C <br /> Owner Home Address <br /> City STATE zip <br /> Owner Mailing Address r0/ S�O� <br /> Mailing Address City C)� <br /> ��yy(( Sfalfe 21P 9thy!o <br /> CORPORATIONIpI INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY El OrNEN❑ <br /> SITE MITIGATION/_ENVIRONMENTAL ASSESSMENT X VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INV[STIOATION_LOP <br /> FACILITY ID# INV# ACCOUNTID PR# FOR ASSIGNED EMPLOYEE LEAo ADENCY:EHDY—RWOCB_DTSC_EPA_ <br /> FACILITYFILE COMPLETE rNEFOLLOWING BUSINESS/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 /> BUEINESS/FACILITY/SITENAME J'xi� �` � I�fT4b� <br /> $RE AOpRE9$ / 8100 ^ IN'1 ./l� SUITE# BDa1NEsa PHONE <br /> J\ ( K <br /> CITY /J •/ STATE zip <br /> l// C�} X5330 <br /> BOARD OF SUPERVISOR <br /> STRICT LOCATON CODE KEYt NE12 <br /> Meiling Address KO/FFERENTfiom FecN![yAddresa Attentlon:orCare 01(opfbnn/J <br /> Mailing Address City <br /> STATE 21P <br /> SICCODE APN# <br /> COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifedabove. <br /> BUSINESSNAME / / Attention:o Care Of (optonR// <br /> w 33 &33>rO,Q00Z <br /> Malling AddressPHONE 7� �3 <br /> ('+ X70 e't-KS Ior t {C ISC� 9!/ C� .�s <br /> CITY \ STATE ^,,, zIP <br /> "' q5;8'3 <br /> 3-3 <br /> as <br /> ACCOOVATAaQgFgq f°rfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applican4 cerfify That 1 am the Oener,Opemloq or Authorized Agent of this Business,and 1 acknowledge that all PEEARTFEES, <br /> PENALTIES,ENFORCEMENICH"GES and/or ffoUSLY CHARGES associated with this operation will be billed tome at the address identified above as the A(COUNTAOOREss for this site. 1 also certify that <br /> all information provided on this application is nue and correct;and that all regulated activities will be performed inaccordance with all applicable SAN JOAQUIN Cru N 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,l 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 sad at the same time it is <br /> provided m me or my represenlafive. / <br /> APPLICANT NAME(PLEASE PRINT) L41 Q,1-1-) SIGNATURE <br /> TITLE / i�/� ! y W TAX ID# <br /> Approved By Data 7 Accounting Moe Precesaing Completed By Dab O f�L-/ <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECKS RECEIVED BY WORK PLAN PE <br /> � <br /> FEE:S2 <br /> J 77 5 J,B22 7�r2 ELENA .!aA"�'�'�� � t�'� /t <br /> 033�FY7 <br />