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San .- -juin County Environmental Health DAp[trtietat 'b' <br /> "Nm-R!' <br /> c » GREEN FORM <br /> jITER FILE RECORD INFORMATION Niro <br /> F EB 2 2 �ATIP MITIGATION &LOP <br /> o b1. IV <br /> - <br /> =P1 <br /> D USEONLY OWNER ID# CASE# �4 ��pB 1 _U_N ITEtV is1�i YIJfVM 1ir ��.eti�_I�'i <br /> OWNER FILETE TNEFOLLOW/NG PROPERTY OWNER INFORMATION.- <br /> CO CHECK/ O N URRE ILYON FILE W/TH EHD <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> EMAIL ADDRESS <br /> BUSINESS NAME <br /> owner Home Address <br /> STATE ZIP <br /> City <br /> owner Mailing Address <br /> `r )2- <br /> Mailing <br /> Mailing Address City Stabs <br /> (f/1- Zip y <br /> a�s� <br /> FzRPORATION❑ INDIVIDUAL P 7 PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MmeATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPEUNE INVESTIGATION_LOP <br /> FACILITY IDN INV# ACCOUNT ID P R08 ASSIGNED EMPLOYEE LEAD AGENCY:EHD " RWQCB_DTSC_EPA_ <br /> 3�3s3 i a <br /> FACILITY FILE COMPLETE 7HEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMATiON: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISTING Business LoCAnON but a NEw TYPE.of regulated Business? YES ❑ No B' <br /> BustNESstFActLRY1SRE NAME <br /> SURE# BUSINESSPHONE <br /> SITE ADDRESS <br /> CRY STATE ZIP <br /> BOARD OF SUPERVISOR DIsTRIcT �Lo-rAT-mw�Com KEr1 - KEY2 <br /> Mailing Address NDIFFERENT from FaclW Address Attention:or-Care Of(opbbewl) <br /> Mailing Address City STATE ZIP <br /> F <br /> C CGDE APN N COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator ident/f/ed above. <br /> BUSINESS NAME Attention:orCere Of(optlwl o <br /> Melling Address PHONE <br /> Cm STATE ZIP <br /> XI <br /> AccoilAT.4ODRESc for fees and Charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BfL TNG AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77ES,ENFORCEMENT CHARGES and/or HOURLy CHARGES associated with this operation will be billed to me at the address identified above as theACCOUNTADDRES$for this site. I also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time itis <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) y� r e \ e ( SIGNATURE <br /> TAx ID# <br /> TITLE ^Tc,s k S-7 — -3-7 <br /> Approved By Dete a Accounting OIRce Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK PUN PE <br /> FEE:$ <br />