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SAN JO COUNTY ENVIRONMENTAL HEALTH DETMENT <br /> DATE 1 ��a()) MASTER FILE RECORD INFORMATION "MFIF GREEN FORM <br /> 3 <br /> ✓ SITE MITIGATION & LOP <br /> ¢f1ApEP�®€A$.Lg EHDUeE ONIv OWNERID# �((/D DI QLJ/lg CARE# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHEcKzFONWERta CURREHTEroARILEWITH EMD E]PROPER'IYOWNERNAME A/EIL �/ /7/`��G"'Sol <br /> FIRST MI LAST PHONENUMRER <br /> BUSINESS NAMd E•MAAADORESS <br /> n/OL O. �7 SUY- �'j' Su �/✓C. /lei .gn[�C/yorr /'1oon�C1r`S .efY� <br /> OWNERHOMEADDRREaR• <br /> �. L,I`XY+F2 SE1VL✓'1frPNC/Y/�D !`��. <br /> CITY STATL-027/ CE <br /> OWNER Mamma ADDRESS <br /> 5,9^1 c r <br /> MAIUNGADDRERRCm STATE ZIP <br /> ❑CORPORATION INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ <br /> FACILm ID# INV# ACCOUNTID 11 PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDX—RWQCB_DTSC_EPA_ <br /> 0212 n0v 6q4-11 A05'm8 $ <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? �,y YES ❑ No ❑ <br /> BuE;WEEu IFACILmISITEfPOI <br /> RECTNAME ftc <br /> -S'/IY qr OG- <br /> SREADDRESSIPROJECTLOCATION SUITE# BUSINESS PHONE <br /> 202 IH*017904- w ;'0151 -347-7 70! <br /> CITY L-D D/ STATE ZIPq <br /> G9 <br /> BOARD OF SUPERVISOR DMTRICT LOCATIONCODE KEY1 KEY2 <br /> MAIUNO ADDRESS. FACILITY IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) <br /> SAMc <br /> MAIUNOADORESSCm STATE LP <br /> SIC CODE = <br /> APN# Comm: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME ATTENTION:ORCARE OF/OPTIONAL/ <br /> MAIUNDADDRESS PHONE <br /> Cm STATE LP <br /> ACCOUNT ADDRESS TO REND FEES AND CHARGES: OWNER❑ FACILITY/BUSINESS THIRD PARTY BILLING❑ <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the(Mme,,Opewda,,AaOamzed Agent,or Responsible Party and I aclmowledge that all PERMIT FEES, <br /> PENALTIES,ENFORCEAILA'ICHAEGES find/or IIOIIRLV CRARGE{associated with this project will be billed to me at the address identified above as the ACCOUI AORRESf for this site. 1 also certify that all <br /> information provided on this application is true and correct,and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDINANCE CODES and/or <br /> STANDARDS and STAT and/or FEDERAL Laws and REGULATIONS. As the undersigned 0...er,Operano-,And...ixedAgent,or Rapormible Parry for the project located above under facility/site address,1 <br /> hereby mole rae the release of any and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRgp41 HEALTH DEPARTMENT as soon as it is available <br /> and at the same time it is provided N me or my representative. �n ..' <br /> APPLICANT NAME(PLEASEPHINT) M`C/` �_ AE oKJ-il, SIGNATURE r_ — <br /> TRLE nLs/(1 TAKID# J ✓ — <br /> APPRO Y ✓ DATE / / ACOdImMOMCEPRMEMINGCOMPIETEDRY DATE <br /> SRE MTfIGATION AMOUNT PAID DATE OF PAYM NT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> �//'5D <br />