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1 San Joan County Environmental Health Deartment DATE r y MASTER FILE RECORD INFORMATION "MFR" GREEN FORM 11 J —R— 13 11 SITE MITIGATION & LOP SHA OEDAREASF0r(EHDU'1EONLY � UNIT 'V DWNt=RIDiI CASE# G-71(q - CHECK IF DWNER CURRFNTLYONFIL@WlrN EHD'�. OWNER FILE:COMPLETE THE1F�OLLOW/NGPROPERTY OWNER/NFORMATIO .[� f/ 2 ...,.,.--`ry�J PROPERDER NAME t f� Tl 61) 'J I� TYWN First M1 Lost PHONE NUMBER BUSINESS NAME F4-MI-AO)REss Y 2013 Owner Home Address 205 1W tGa� I rr�r, •1,- , city r,.v eLOL �a SYA ^ ZIP Owner Mailing Address ,f-�i- l/�J Ci5 a�oU-t Mailing Address City State Zip CORPORATION 6 INDIVIDUAL© PARTNERSHIP❑ FED AGENCY❑ OTHER 3rrr MiTwATIO ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INV STIGATION_LOP/ FACILITY IO# INV# ACCOUNTIO PR#!RO# AS SIGNED EMPLOYEEiff- EHO RWQCB_DT3C_EPA_ 35oS�. S ) FACILITY FILE COIMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFQRMATION.' Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ ND, is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No BUSINLsafFACIurYISITE NAME - !� � �7C r �L I✓�f�SS Swe ADDRESSI �y .r SUITE fI BUS! ESSPHONE CITY ST TE zip on BOARD OF SUPERVISOR DISTRICT C LOCATIONCOOE Q� KEY1 KEY2 Mailing Address 1fO1FFEREIVTfrvamPaa11yAddress Attention:orCare Of fop&wal) Malting Address City STATE Zip SIC CODE APN# COMMENT: THIRD PARTY 13ILLING INFO: Compete if Billing Party is different from PrRperty Owner or Facility Operator identified above. BUSINESS NAME _ UU✓I W-6 i ]t7 1 G Attention:orcarn of toptlorrsq Mailing Addreas 1/rl PH NB Clrr j} 1 Sr ZIP q. ;'/—S ACCtlU&T-Aaa E39 for fees and charges OWNER FACimy/BusiNESS THIRD PARTY BILLING'-e-` RtI.1.INC AND COMPLIANCE ACKNOWLEIICNIIINT: 1,the undersigned Applicant,certify that I am the Owrrer,Operator,or Authorized AgeRl of this PERFrn-FEES, PENA1.776P,ENFORCEMEM•CIIARGESandlor 11UlIRLVC11ARf:ES nssoeiMed wilt this operation will be billed to ale at the address identified above as five ACCOUM'A11r3RFkC for this site. I also certify that nn'information provided on this npplicnlion is true and correct;and that nit regulatrd nclivilies will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes andlor Standards and STATE nndfor FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the properly loented at the above Facility/site address,I hereby nuihor4e IJre relense of any and all results and environmental assessment information to SAN JOAQUIN COUN'rY ENVIRONMENTAL IIEAi rFI DEPARTMENT as soon as it is available and at the-dame lime it is provided to 1110 or my representative. APPLICANT NAME(PLEASE PRINT) Sn` OC� �1 SIGNATURE f f., TAX ID 11 la-ail TITLE {'vY/�f .Approved By Dots Accoungng ORloe Processing Completed By Date SITE MITIGATION AMOUNT PAID DATE OF PA MENT PAYMENT TYPE RECEIPTS CHECK RECEIVED BY WORK PLAN PE FEE: i