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San J,,�quin County Environmental Health L„,,artment DATEILMASTER FILE RECORD INFORMATION "MFR" GREENFORM 4/(, � C71 SITE MITIGATION& LOP SHADED AREAS FOR EHD USE ONLY OWNER IDS I �C�ASEI# UNIT IV OWNERFlLE:COMPLETE THEFOLLOWA(GPROPERTY OWNER INFORMATION.' CHECKrFOWNERCURREN71YONFILEWfrHEHD PROPERTY OWNER NAME S T= 'P V J _,—FirsstMI Last PHONE/NUMBE>(.4IC) 561 [l. 2-,q BUSINESS N0AE ?7 E-MAIL ADDRESS Q0 ��A,f,l�-15�c c� TU LL� '7j �`' �.'t`'�. Owner Home Address city STATE ZIP Owner Meiling Address Mailing Address City state ZIP I CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ (10AGENCY IXL. OTHER El SITE MITI(IATION_ENVIRONMENTAL ASSESSMENT L-1/VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP_ FACILITY ID* INvi ACcouNrlD PR 01 PW ASSIGNEoEM OYES ILFADAGENcy:EHD—RWQCB_DTSC—EPA_ o�l4bb1 �RDb D3`� SST- 5L.y t2Z V FACILITY FILE COMPLETETHEFOLLOWAfG BUSINESS/FACILITY/SITE/NFORMATlom Is this a NEW Business LOcATIoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Is this an EXISTING Business LocanON but a NEW TYPE of regulated Business? YES ❑ No BUSINESS/FACIILITY/SITE NAME SITE ADDRESS r ^ f ( � � j SUITE U vBUSINESS PHONE 1RIWrrQl> ljra . p CITU �ljS .STATE ZIP [BOARR:.-:SUPERVISOR DISTRICT LOCATION CODE KEYS KEY2 Mailing Address ifDIFFERENTfromFaci/ityADldress Attention:orCare Of(optional) Mailing Address City STATE ZIP 31C CODE APN S COMMENT: / THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. BUSINESS NAME .-�- Attention:orCare Of(option/J � jtt—Y A r ' 1G tt_L.fuG Ne Mailing Address 7 PHONE t aA) 415 -4�i ---7G,?- . Cnr t�, ff ..22 r y +-/I 1I � K.�'F `r.~.`'^:,4.. STA ZIP �4 L' f AGDQueTAoOBE&s for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPIA ANCE ACKNOWLEDGMENT: 1,the undersigned.Applicant,certify that 1 am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PER:vir FEE,%, PENAL T7ES,ENFORCENEN7'01ARGES and/or f/OURL Y CHARGES associated With this operation will be billed to me at the address identified aboN'e as the ACCOL71TA-yn E,CS for this site. 1 also certify that all informafien 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 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,I hereby authorize the release of any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENNIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis provided to me or my representative. APPLICANT NAME(PLEASE PRINT) lI"( ia'-/' SIGNATURE c� �Lr f� ✓rJ Lf/` TITLE TAX ID# Approved By Date Accounting Office Processing Completed By Data SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPTS CHECK/ RECEIVED BY WORK PLAN PE FEE:$