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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> 4HAQED AREAS FDR EHE uBE ON LC OWNER IDN CAME= UNIT IV <br /> OWNER FILE:Compi E7E PROPERTY OWNER/RESPONSIBLE PARTY AfFORmA77oN. CHECKh' OWNER CURReMnravncewirH EHD <br /> PROPERTY OWNER NAME — <br /> 71, - 'jcjOO <br /> First MI Last PHONE NUMBER <br /> BusINESS NAME E-MAIL ADDRESS <br /> Owner Homs Address <br /> City STATE LP <br /> LSA Gf'� ��s v <br /> Owner Mailing Address <br /> G <br /> Magkvg Address City State LP <br /> 'mCORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GovERNMENT ADENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SrrE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDN INV# ACCOUNT IO PR V RO# AesloN®Ewan om Um MENcr EHD_RWQCB_DMC_EPA_ <br /> FACILITY FILE: ComPLE7E BUSINESS/SITE/PROJECT/NFoRw7roN. <br /> Is this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES Ley No ❑ <br /> IS this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? YES ❑ No <br /> BUa1NE s&'FAciLfiYISRPJPRoiwT NAME <br /> SITE ADDRESS I PRoJECT LOf.ATIOq 1857E# Bue1NEAs PHONE <br /> L1Hh�r� C 5tr a.^F R�. MWr? f G� SF, v11z-2 <br /> CITY STATE L► <br /> L�+h rp CA CIS-330 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address/fD1FMRE rftm FsclllfyAdidress Attentlon:or Cam Of(opEtaraso <br /> Mailing Address City STATE LP <br /> SIC CODE TN N 7COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orResponsible Party identified above. <br /> BUSINESS NAME Attention:cr'Care Or (dpNonW) <br /> G a <br /> Mailing Address PHONE <br /> Z O 10 f. S tc:. ZS d Li Z�� `3 <br /> CITY STATE LP <br /> AcizougrAgaram for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING x <br /> BIL I G ANP CQNVLIANCE ACKNOWLEDCMENT: I,the undersigned Applicant,certify that I■m the Owner,Operator,Authorized Agent,or Responsible Parry and I acknMedge that of PormiT FEES, <br /> PENALTIES,EA'FORCE.MEt7 CHARGES and/or l/oL'RLY CHARGES sssocielLd with this project will be billed tome at the address Identified above as the ACCOi,;17 ADARESS for this site. 1 also certify that all <br /> information provided on this application is true and correct;and that all regulated activities will be performed In accordance with all rpplicable SAN JOAQL9Y COt1NTY Ordinance Codes and/or <br /> Stamdards and STATE and/or FEDERAL Laws and Regulations. As the undersigned Owner,Operator,Authorized Agent,or Responsible Party for the project located above under facilitylsite addrtss,I <br /> hereby authorize the release of may and all results,reports,and other environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it <br /> Is available and at the same time It is prmVided to me or my representative. <br /> APPLICANTNAME(PLEASE PRINT) �/Cerl�4 eu i Ilrr SIONATuRE <br /> TITLE TAx ID# <br /> Approved fly Datil Accounting Once Proceahq Completed By Data <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORK PLAN PE <br /> FEE:S <br />