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r San Jop—sin County Environmental Health:1 Dn;3artment <br /> DAA �/r�111 MA R FILE RECORD INFORMATION " �' <br /> GREEN FORM <br /> I' SITE MITIGATION& LOP <br /> SHAOEn AREAS FOR EHD Use ONLY OWNER/Dai CASES <br /> UNIT IV <br /> OWNER FILE:ComPLETETwFoLww/NGPROPERTYOWNERlwomAnow CHimiFOWNER CURREN7LyoNnLEwmEHD <br /> PROPERTY OWNER NAME 71 f <br /> — RZ <br /> First Mt Last PHONE NUMBER �p / <br /> BUSINESS NAMEE II E-MAILAODRESS <br /> i <br /> Owner Home Address <br /> STATE 9 S2 r <br /> CftOwner MaIMV Address NAr- <br /> Malting Address Oily S Zip <br /> i <br /> I <br /> CORPORATION❑ INDMDUALff, PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SM MITIGATION_ENVIRONMENTAL ASSESSMENT_VOWNTARY CLEANUP—WATER QUAuTY NW PIPBUNE INVESTIGATION_LOP <br /> FACILITY 10 INV# ACCOUNTID QS 6rSIGNEDEMPLOYET EA6AGENCY:EHD RWQCB,, oTSC_EPA <br /> 3 D 1 ��` <br /> FACILITY FILE COIfPLETETHEFQLLOWNG BUSINESS I FACILITY/SITE INFORMATION,' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENIr? YES ❑ No Fer <br /> Is this an E 06nNo Business LOCATION but a NEW TVP£of regulated Business? YES ❑ No <br /> SusiNESSIFACILnYIS1TENAME <br /> r J I <br /> SREADDRE3S 32- ^�'� t SUITE BUSINESS PHONE <br /> J iJ <br /> CITY //►� j{ STATE 75PBOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY 1 KEY2 <br /> I <br /> Mailing Address/fOIFF1=REWfitam FadlHyAdWrew Atte)tlon:orCare Of Apftr-v <br /> e1i pr- <br /> Mailing Address City STATE ZIP <br /> SICCaDE APN# -Dll Y S- COMMENT: ib <br /> �vl�L 1 S`rrt c c a1v rr e /';0( ;2 ,0)1 � <br /> Ai�¢ca Ae�pe rs ocv n�s <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Own! f�j �tK1 <br /> BUSINESS NAME l`i r V i- Laivrb e-rf i <br /> Mailing Address 's 3? SLC64,� l L O d, J CR 9 5 Zqo I t <br /> CITY �/ CG3o) - 9G$ -elo90 <br /> 2)4vr,d So 14 <br /> i <br /> for fees and Charges OWNER FACILITYIBuI 4 OS we- <br /> '�'�'rC <br /> Lod .) C; g S- 2SF0 <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Ownf,operator,Or.A, ! 70y) Iy <br /> PrnGtrrFs,BrvFolacF�rtkNrC[inxaEs and/or AouxLrt"rrtecr s associated with this operation will be billed to meat the addrea '� 3G _7 <br /> f 0 r f� <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accort <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the propertyl 3, Th o m&r- <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL1 e <br /> provided to me or my representative- <br /> APPLICANT <br /> epresentative / <br /> APPLICANTNAME(PLEAsEPRINT) lad I t �I ,rs SKMATUQ <br /> ii 1 t+ -` 5'3LL. <br /> TITLE �a F — TAX lD � . � g9 .?.o•a -- <br /> Approved By Onto Accounting Oalce Processing Completed By' Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECKJ s RECEIVED BY - WORK AAN PE <br /> FEE:$ <br /> I J <br />