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San Joaquin County Environmental Health Department <br /> DATE q .�1 I iVASTER FILE R,-CORD INFOR;1ATION "Z;A_R32 GREEN FORP4 <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR..EHD USE ONLY <br /> OWNER ID# CASE# l�)�� r U <br /> =y��Ll'?LL CCr ,:COMPLETETHEFOLLOW/NG PROPERTY OWNER/NFORMATlom CHEC/UF OWNER CURRENTLYON FILE WITH EHD El <br /> PROPERTY OWNER NAME ( / <br /> ^— l First MI —��-- Last PHONE NUMBER P-K, 3' (1 <br /> BUSINESS NAME �� E-MAILADDRESS s11 <br /> SY9 <br /> Owner Home Address ' <br /> --30_ <br /> City ot 'v STATE ZIP <br /> Owner Mailing Address <br /> Mailing Address City l j;� j. State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION -ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY�NrJ PIP-E-4 Z INVESTIGATION_LOP!_ <br /> FA # INV# ACCOUNT ID PR#/RO# i ASSIGNED EMPLOYfcc LEAD AGENC.YYEHD :3WQC8 DTSC EPA. 33 ' <br /> Lj <br /> COMPLETE THE FOLLOW/NG BUSINESS/FACILITY)SITE&FORMAT/ON: <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 /> BUSINESS/FACILITY/SITE NA E <br /> SITE ADDRESS UP SUITE# BUSINESS PHONE <br /> OITY .I—r—' � � STATE zip <br /> BOARD OF SUPERVISOR DISTRICT LOCATION LOCATION CODE KEY1 I' KEY2 <br /> Mailing Address ifDIFFERENTfrom Facility Address Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE � APN# COMMENT: <br /> 'i'HIRD DARTY MILLING:NFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Y�(„ CA `• i 1 t Attention:or Care Of (optional) <br /> Mailing Address PHONyt, �-. <br /> .� <br /> �D5 1 LLA o�(JGI' uApi - 7� <br /> 3 <br /> CITY � STATE ZIP <br /> Aactu mrADDR,ws for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND CON'IPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PERAHTFEES, <br /> PENALTIES,ENFORCEMENT CHARGES and/or HOURLY CHARGES associated with this operation will be billed tome at the address identified above as the ACCOUNTADDRESS for this site. I 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 STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,op ator,or agent of the property located at the above facility/site address,I hereb thorize the release of <br /> any and all results and en0romnental assessment information to SAN JO UIN COUNT NVIRONNIENTAL HEAL EPA TIMENT as soon as it is ava' =and the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE , TAX ID $ <br /> Approved By Date Accounting Office Processing Completed By <br /> SITE YI'IG/ATION 1:AfA0UN7 PAID IIS DATE pFPAY"""T PAYP.tENT TYPtoe �I RECEIPT# �' CHF RECFED BY WORK PLAN PE <br />