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San Joaquin County Environmental Health Department <br /> DATE �,�� Z0�v MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> tiHADCD AREAS FOg_ {Dy�E ONLY OWNER ID# CASE UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOW/NG PROPERTY OWNER/N(FORMAT/ow CHECNIF OWNER CuRRelvarovFxEwrrN EHD <br /> PROPERTY OWNER NAME w• 21 <br /> Fasf Ml Last PHONE NUMBER <br /> BUSINESS NAMEE-MAIL AD�+E88 ri-5 4n4+eS <br /> (J2S ca����CNVIIC(_ a,;,L--fG . r', ( (6. Al�Cl175 l�cScq @ Thrif-t( (rte <br /> Owner Home Address <br /> City STATE ZIP <br /> Owner Mailing Address nI <br /> "5 ( �t b�lGl <br /> Mailing Address City Stato Zlp <br /> �Vz s <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION LOP <br /> FACILITY IO# INV# ACCOUNT ID PR#/RO Is ASsIONED EMPLOYEE LEAD AGFNCY:EHD_ RWQCD_DTSC EPA <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/oN: _ <br /> Is this a NEw Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? res ❑ No <br /> Is this an EwSTING Business LOCATION but a NEW TYPE of regulated Business? YES No ❑ <br /> BUSINEss/FACILITY/SITE NAME <br /> MO <br /> SITE ADDRESSI SUITE# BUSINESS PHONE <br /> fP LCI i c rl-\Ve— <br /> CITY STATE ZIP <br /> JK <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE EY1 KEY2 <br /> T— <br /> Mailing Address NDIFFERENT frvm Fncl1/ty Addross Attention:orCare Of(optlonal) I <br /> I <br /> Melling Address City STATE ZIP <br /> SIC CODE APN# � COMMENT: <br /> THIRD PARTY BILLING INPO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCaro Of(optlefWi)` { i <br /> Melling Address PHONE- <br /> � <br /> U ' I DO <br /> CITv V �Na STAT ZIPCAVkrjA <br /> ACQoagrAm mess for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING \ <br /> BILLING AND COMPLIANCE AcKNo\YLEDGl-IKNT: 1,the undersigned Applicant,cerfih that 1 ant the Owner,Operator,ur Authorized Agen!of this Business,and I aclutowledge that all PERStir h'eate. <br /> /'ENALiTES,F.A'FORC7sIf.N1'C7URGE.T and/or HOURLYCltdR6ES associated with this operntiun will Ire billed to me at the address identified above its the ACO.-o<Byr AnnRt.'.Kt'for OILY site. I also certify[hat <br /> all Information provided on this application is tau and correct;and that all regulated activities w'lll be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and 1T.%ry and/or I-'P[DF.w Lan:and Regulations. As the undersiCnrd rmncr,operator,or agent of fhe pwperh loca(cd al du above hucilify/site address.1 hereby authorize the release of <br /> any and all results and enAronnenil nssessmem information to SAN JOAQUIN COUNTY ENVIRONNIBNTAL IIFALTII DEPARTMENT'as soon as it is available ami 11t the same tinte it is <br /> provided to me or my rrpresentatitc. <br /> APPLICANT NAME(PLEASE PRINT) LGI:wZtI/�/ // }I( SIGNATURE! <br /> TITLE V u�f i( TAX ID-#- <br /> Approved By A.—ting Office Procaaunq Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMCNT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PUN PE <br /> FEE:f <br />