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r <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" <br /> GREEN FORM <br /> SITE MITIGATION&LOP <br /> 9HAOED AREAS FOR EHD USE ONLY OWNER IDN .CASE#SU UNIT IV <br /> G7 <br /> OWNER FILE:Commg'ETHEFOLLOW%NG PROPERTY OWN ER/NFORMATION. CHEC!(/f OWNER CURRENTLYpNFILEW?NERD <br /> El <br /> PROPERTY OWNER NAME �.1 ( ) —�� <br /> Fl r MI Last PHONE NUMBER <br /> BUBINF•83 NAME E-MAILADDRESS <br /> Owner Home Addreae i <br /> City BTA ZIP <br /> aWnar•MBlling Addrgas <br /> J <br /> Mailing Address City State ZIP <br /> I <br /> CORPORATION INDIVIDUAL❑ PARTNERSHIP❑ FED AGEKCY❑ OTHER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSEs3MENTYVOLUNTARYCLEANUP_WATERQUALITY_HIWPIPELINE INVESTIGATION_LOP^ I <br /> ,... - <br /> FgoluTY IU N INV# AoCOUNT 16 •'PR#/Rb# AseiGNED PLOYEE -LEAD AGENCY:EHD. RW4C6 DTBF_EPA <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITY/SITE l/VFORMATION: <br /> Is this an EXISTING Business LOCATION but a NEWTYPE of regulated Business? <br /> YES El No <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DIE PARTNI ENT? YES No El <br /> BUSINEsa(FAc%rry18ITE NAME <br /> i <br /> r t <br /> -$READDRESS f� '� SUrTE# BUSINESS PHONE <br /> Orly U u I <br /> sT ZIPS <br /> BOARD OF SUPERVISOR DISTniaT / LoOAmoN CODE KEY1 <br /> Mailing Address I/D/FFERENTfromFaa///(YAddress Attention:orCare Of(optlonal) <br /> I <br /> Mailing Address City STATE ZIP <br /> 1 <br /> CODE- ... APN# <br /> .; .COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party Is different from Property Owner orFacllity Operator idenUtledabove. <br /> BUSINESS NAME Attention:orCare Of(opl/ona1J <br /> Melling Address / PHONE <br /> (my, <br /> Cm <br /> BT Te tj ZIP���� r.J <br /> A= <br /> o rNrAone for fees and Charges OWNER FACILITY/BUSIN S THIRD PARTY BILLING <br /> BILLING AND CO\IPLIANCP A.CI(HOWLFD A1FM'; 1,11 ndeni6ned Applicont,Certiry(lint I am the ONvrer.Opernfnr,or An rorize gcua of this 0 tsines5,and I nclmo,rlCdge that all pfiltA?/TEG$ <br /> PSA'Al,TfPS,ENFORCEflL•M'CfrAROIIS Boll/or 1/OURI.i' H tGES nuoclalcd,villi ods operation will be billedto me at the nddres WCnI d above ns the 'rnun�' n :,•far this site.I also certify that <br /> All information provided on this Application is tru n I cAt'reeh,And that All regulated Activities will be performed In nceor i ith nil applicable ANJOAQUIN COUNTY Ordinance Codes and/or <br /> Standards And STATS And/or IPEDERAL Lnu•s nn a ulnlions.As the und"Allno owner,operator,or agent of the properly las I at the above foeili •/site address,1.hereby authorize lho t•cicnse or <br /> Any And All results a cnvirona tnl Asse.Csn n nformntion to SAN AQU COUNTY ENVIRONirl ENTAL HCAL'T EPART'ATENT ns so It As It is available nod at the sante time it is <br /> p APPLI to nice , representative, <br /> APPLICA ME(PLFASEPRINT) Com, / <br /> •'�/ SIONAT R <br /> TirL �J TAX I <br /> A roved D Date Accounthill ORIee Pr000saing Completed By Dale I <br /> SITE MITIGATION AMOUNTPAID DATE OF PAYMENT - "PAYMENTTYPE REOEIPT# CHECK# -,RECEIVED BY WORKPLAN PE <br /> FEE:$ I2 75 - <br /> �s� 3-57 a9 sa <br />