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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT DATE 1 MASTER FILE RECORD INFORMATION "MFR" GREEN FORM SITE MITIGATION & LOP SHADED AREAS FOR EHD USE ONLY OWNER ID# r` CASE# UNIT IV OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: CHECK IF OWNER ISOURRENrLYON FILE wtrH EHD El PROPERTY OWNER NAME I A L"'-C, 1_1 5) Uv�_ -r7 7 3-� FIRST tdl I`iL'l-LAST PHONE NUMBER !� BUSINESS NAMEE-MAILADDRES9 `TY2-1 '—C 0, +40vv&a� r�C ALC-C CTra o , I or OWNER HOME ADDRESS Z� Z? �j.i i i-t ✓�`K�LfkYL 1 Y� J�L j/j_. CITY STATE ZIP TIz C-y C, OWNER MAILING ADDRESS MAILING ADDRESS CITY I STATE ZIP may/ LTJ CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION LOP FAOILITYID# INv#. AocouNTID p� PR#/RO# A991GNEDEMPLOYEE LEAD AGENDv:EHDRWQCB_DT3C_EPA_ FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No (D, IS THIS AN EXISTING PROJECT LOCATION,BUT ANEW SCOPE OF WORK? YES No ❑ BU9INESSIFACILITYISITEIPROJECT NAME � 3J rc� �L+✓U�fZ SITE ADDRESS/PROJEOT LOCATIONSUITE# BUSINESS PHONE 2 25 CCn'� oAf'C-&vZ7 w C,-L- —1�:'(L -c6C+- CITY STATE ZIP BOARD OF SUPERVISOR DISTRICT S LOCATION CODE 3 KEY1 KEY2 MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL) MAILING ADDRESS CITY STATE ZIP SIC CODE P�p N# I _U COMMENT: THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. BUSINESS NAME ATTENTION:ORCARE OF (OPTIONAL) MAILING ADDRESS PHONE CITY STATE ZIP ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER❑ FACILITYIBUSINESS❑ THIRD PARTY BILLING❑ BILLING AND COMPLIANCE.ACKNOWLEDGMENT: I,the undersigned Applicant,certify flint Into the Owner,Operator,Authorized Ageld,or Relpotuible Parh,and I aclmoadedge that all PER.UIT ILFS, PENALTIES,LNF0RCr%1F.N'C1IARGFS and/or HOURLYCHARGF_S associated with this project will be billed to me tit the address identified above as the ACCOUNTADDRESS for this site. I also certify that all information provided on this application is true and correct;and(lint till re6nilaMd activities will be performed in accordance with all applicable SAN JOAQUIN COUNIY ORDINANCE CODES and/or STANDARDS and SPATE and/or FEDERAL Laws and REGULATIONS. As the undersigned Oa-ner,Operator,ANtborired Agent,or Responsible Par(v for the project located above under facility/site addres9,I hereby nulhorize the release of nny and all results,reports,and other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL I lEAL'rn DEPARTMBNr as soon as it is available and tit the same time it is provided to me m•illy representative. APPLIOANT NAME(PLEASE PRINT) A SIGNATURE TITLE T,ax ID# r PROVED BY DATE ACCOUNTING OFFICE PROCESSING COMPLETED BY DATE TE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPI E RECEIPT# CHEOK# REOEIVED BY WPLANPE E: rte. zsb