Laserfiche WebLink
San u0ounty Environmental HealthWaSent <br /> DATE /Z y f MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> S FOREHDUSEONLY OWNER <br /> IO#0 CASE{ UNIT IV <br /> OWNER MLE:COMPLETE MEFOLLOW/NG PROPERTY OWNER INFORMArloN. CMEZ(fiz OWNER CuaaavnroNHLexffft EHO � <br /> PROPERTY Owm en NAME <br /> First MI Last PHONE NUMBER <br /> BUSINESSNAME 6 I.Aowess <br /> Owner Horne Ar11Mess <br /> city STATE zw <br /> -k <br /> Owner Melling Address n <br /> Mailing Address CRY n t BtAts ZIP ; ! <br /> CORPORATIONS INDIVIDUAL❑ PARDRERN-11P❑ F®AGENcsEl OTHER El <br /> Srm MmeATioN_ENWRONMENTAL Assmanaff VoLMNTAIIY CLEANUP_WATin QuAurr_HW PIPELINE INvesTTOATioN_LOP <br /> FAciurr'IDS INV# ACCOUNT ID PRWROS ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWQCB_OTSC_EPA_ <br /> Do DO 145-9 <br /> FACILITY FILE Compum 7HEFoLLowAAG BUSINESS/FACILITY/SITE INFoRMnnoN. <br /> Is MIS a NEW Business LOCATION not previcusly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO Q <br /> IS this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No Q <br /> BUSINESSIFACILRYIBITENAME <br /> L Z <br /> SITEADORESS � , `/1 SUITE# BUSINESS PHONE <br /> CmSTATE LP <br /> -'7c.1L K r 0Ati C 5 .� ✓� <br /> BOARD OF SUPERVISOR DISTRICT LDGAHDH CODE ItEa'1 KEv2 <br /> Meilhg Address IfDIFFEREWthem FaeftAddress /J AttenBm:erCare Of feledaasq <br /> n 'c ' i�n, Fr <br /> Mailing Address City STATE ZIP <br /> tL,g .k. <br /> rs — <br /> ODE APN# COMMENT: <br /> 28D F1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Ate:QrCare Of fDPMGrw/ <br /> Mailing Addreu �r rr II 'I <br /> / 1-3 W /CJS J / (a 6 ) 6 / 81/ <br /> Cm /,r STATE LP <br /> {Aq 2 G 2 : r%"f C/1 el r4-1 <br /> Alamo P6aaMES4 for fees and chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned AppllranL certify that I am the(hVM,Opemmr,or Authorized Agent of this Business,and 1 acknowledge that all PRRMn FSEs, <br /> PEM' TiEs,ENFTMCEMEMCHARGES and/or HouREP6uf;ES asameinted with this operation will be billed to meat the address identified above as the ActMAYADDREsS for this Site. 1 also certih that <br /> at information provided on this appliention 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 endlar FEDERAL lbws and Regulations As the umlemigmd owner,operator,or agent of the property located at the above facility/ate address.I hereby authorize the release of <br /> any and all result and environmental assesament information to SAN JOAQUIN COUNTY ENVURONMENTAL HEALTH DEPARTMENT As Soon As it is available and at the some time it Is <br /> provided to me or my representative <br /> APPLICANT NAME(PLEASE PRINT) BIDMMURE'.=.. <br /> TITLE / / _ TAX ID <br /> 1 <br /> Approved By Defe Accountmg Offk*PYx%rMmg COmpktod By Date IO 3 <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE REDEIPT# CHECK# REDEMM BY WORK PIAN PE <br /> FEE.f 3GG,D0 5393 X9So <br />