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San Juin County Environmental Healtpartment <br /> 6199 » GREEN FORM <br /> DATE I� MASTER FILE RECORD INFORMATIONR SITE MITIGATION & LOP <br /> SHADED AREASFOREHD USE ONLY OWNER ID# <br /> CASE# UNIT IV <br /> CHEC/f/F OWNER CURRENTLY ON FILE WRH I El <br /> OWNER FILE:COMPLETETHEFOLL OWING PROPERTYOWNERINFORMATION. `) <br /> PROPERTY OWNER NAME <br /> First MI Last PHONE NUMBER <br /> E-MAIL ADDRESS <br /> BUSINESS NAME <br /> US <br /> reY tt_K OI-11t <br /> Owner Home Address <br /> lZ �— <br /> STATE ZIP <br /> City C <br /> Owner Mailing Address <br /> State Zip <br /> Mailing Address City <br /> CORPORATIONIGtyI INDIVIDUAL F-1 PARTNERSHIP FED AGENCY El OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHDRWQCB DTSC_EPA <br /> 0*14 ouo 0 81 <br /> FACILITYFILE COMPLETE THE FOL LOWING BUSINESS/FACILITY/SITE INFORMATION- <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ NO ❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BUSINESSIFACILITY/SITE NAME <br /> SUITE# BUSINESS PHONE <br /> SITE ADDRESS <br /> STATE ZJP <br /> CITY <br /> BOARDOFSUPERVISOROISTRICT LOCATION CODE KEY1 KEY2 <br /> Mailing Address ifDIFFERENTImm FacilityAddrass Attention:or-Care Of(optional) <br /> STATE Zp <br /> Mailing Address City <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identified above. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> PHONE <br /> Mailing Address <br /> STATE ZIP <br /> CITY <br /> A A OREsc for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Omlar,Opemror,orAuthorized Agent of this Business,and 1 acknowledge that all PERNITFEes, <br /> PIEA'FORC&VENT CHARGES and/or HOURLY CHARGES msociated With this operation WIII be billed t0 me at the address Identified above as the ACCOOMADDRE55 for this site. I 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 applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned money operator,or agent of the property located at the above facility/site address,1 hereby authorize the release of <br /> any and all results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT assoo as it is s available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANTNAME(PLEASE PRINT) K�` -fy� SIGNATURE�y <br /> TAX ID# <br /> TITLE <br /> Approved By Data Accounting Office Processing Completed By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORK NPE <br /> FEE: ,rf/tlfl <br />