Laserfiche WebLink
l }}} San Joaquin County Environmental Health Department <br /> I DATE MASTER FILE RECORD INFORMATION"MM"' GREENFORM <br /> M r� _ SITEMITIGATIONMITIGATION& LOP <br /> SffADEn AREAS FOR END USE OM OWNER IDtI CASE f1[�M� UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOYYING PROPERTY OWNER INFORAfATrom CHFcxlr OWNER Cu11.17LYONAILewrm EHD <br /> $ PROPERTYOWNERNAME <br /> ! First YL AV Last PHONENUMBER <br /> BUSINESSNAME E-MAILAODRIS, <br /> f!' Owner Home Address �� �n <br /> City �` G• C STATE zip n_ <br /> 7'4 <br /> Owner Mailing Address <br /> Mailing Address City Q`"[(O 764 I gla{D ZIP <br /> QS 3 <br /> CORPoRATIDN INDIVIDUAL i] PARTNERSHIP❑ FED AGENCY© OTHER❑ <br /> SITE MITIGATION� ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP—WATER QUALrrY_NW PIPELINE INVESTIGATION_LOP <br /> FACILITYIDO INVN ACCOUNTID PIR 0 AsStONEOEMPLOYEE LEAD AoeNOY:EHD „�•,,,,,_RWQCB_DTSC_EPA_ <br /> G"l 144 T. <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS I FACILITY/SITE INFORMATION.' <br /> Is this a New Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES © NO � <br /> 1 <br /> Is this an ExISTING Business LOCATION but a NEwTYPE of regulated Business? YES © No <br /> BUSINESSIFACILITYISITENAME <br /> SrTEADDRESS SUITr:# BUSINESSPRONE <br /> CITY STATECX ZIP <br /> BOARD OF SUPERVISOR DISTRICT Jos LOCATION CODE OKayll <br /> Mailing Address 1f01FFERENTfrvm Fac1111yAddress Attention:orCare Of(opOonal) <br /> i <br /> Mailing Address City STATE ZIP <br /> SEC CODE7APN ft COMMENT: <br /> 3S'GW -ZN <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaaility Operator idenfirled above. <br /> SUSINESSNAME Attention:orCare Of(aptlonaV <br /> !Nailing Address �� PH <br /> CIN Cir sT ZIP 5 <br /> i <br /> A_CO3aV LA0,ORESS forfees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> 1SILLINC AND CO.IIPLIANCE ACICNOWLEUGAtENY: 1.The undersigned Applicant,cerlify that 1 am the O v rer,Operator,or Artrhariyed Agva1 of this Itusiness,and I acknmrledge itall all Frit Ur FEES, <br /> PF.NAL7'IFS,FVFORCt:,IttRV'r CHITRGES aadlor AOLIRLYCHARGES a990d.11ed Willi this operatnn Evill be billed to air al Ilia address Idrntilled above as Ile ArC0[j VTA1)I)S for this Site. I also cerlify that <br /> all hil(Winaiion proVicled OR INS rlpplleallon is true ind Correct;and(Ilii all regUtaled neti5i11e5 11 Ill be perforinell In accordance With SII nppllcalllQ SAN JOAQIi1N COUN't•Y Ordinance Codes and/or <br /> f Standurds and STATE and/or FEDERAL Laws and Regulations. As Uhe undersigned owner,operator,or agent or the property located nt Ille above facitity/site address,I hereby rurlhorize the release of <br /> h any and all results and emiromnen(al assessrilenl inrnrniation to SAN JOAQUIN COUNTY ENVIRONNIFNTAI,FIFALTU DEPARTAIF.NT as soon as IF Is available and at the same time it R <br /> prnsidrd to mr or my represratailve <br /> 2` <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> ie e- <br /> PTAX ID# <br /> TITLE oFDw yr <br /> Approved Cy Onto Accounting Once Processing Comptotod By DRIB <br /> SITE MITIGG/A,TTIION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPTS CHECItf1 RECEIVEDBY WORN PLAN PE <br /> FEE:$ 1'_-� '35 Z� <br />