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San Joaquin County Environmental Health Department <br /> DATE MAdTER FILE RECORD INFORMATION"*mss' GREEN FORM <br /> SITE MITIGATION& LOP <br /> $KanaOAUM Egg EHO USEOHLy OWNER ID#. LCAIE# ? UNIT IV <br /> OVMER FILE:COAfPLETL'TflEFOLLOWAAG PROPERTY OWNER A(F RAfAy7oN., CHECKIF OWNER CURREA0X3`0NRct•m7rt EHo <br /> PROPERTY:OWNER NAME 0—fl. V <br /> V :First Mi Last PHONE NumsER <br /> Wsmss NAME E-MaL ADOREss <br /> Owner Home Address <br /> city <br /> .STATE ZIP <br /> l l <br /> Owner Melling Address <br /> Malting Address Cfty <br /> CORPORATION iNonnouAL❑ TMI PARTNERSHIP❑ FEo AGENcrCt.❑ OTHER❑ <br /> 3Rft"MIl7QATION. 'F:Nv RONMR NTAL AWassmoff_VOLUNTARY CLMNUP._._:WATER QUALITY HW PIPELINE IRVW"GATWN_Lop A_G,e <br /> FAgLITYID# INV'# AocouNTID R1?# A$$IGNEOEMPLOYEJ�LEAo AGENCY:EHD�RwQGB� DTSC—EPA_ <br /> o $5 �t3 6 i` i; <br /> FAGILITYFILE COMP[FrETHdEFOILO +tNGBUSINESS/FACILITYISITEINFORMAI7©N.• <br /> Is this a NEW Business LOCATION not previously regulated by the,ENmRONNmENTAL HEALTH DEPARTMENT? YES ❑ No rK <br /> Is this an EXISTING BuskTessr LWATION but a NEwTYPE of regulated Business? YES ❑ No <br /> Make- -.1 Cor-6s at c, <br /> `,4TEAboREss SUITE# BUSINESS PHONE <br /> U <br /> Cleat2 <br /> ���L. �, 8TA ZIP <br /> BOARR OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KEry$' t <br /> Malling Address!lvtFFERENrfrcmBacftAd rew Attention:urCere Of(opffonsig <br /> Melling Address City STATE 7JP <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaGility Operator identified above. <br /> eustNm Nam O f7 F` i n Aftakno 1:QPC we of( ) <br /> MaHlIVAddress PHONE (fv) q t +� <br /> �co 1 <br /> CITY STATE ZIP <br /> S72 <br /> 1 <br /> AommtZ s forfaes and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Owner,Operator,or Authorized Agent of this Business,and I acknowledge that all FEAWT FEES, <br /> PEhucrrEg ENFoRcEMENTCHARaEs and/or HouxtYCHARGE`s associated with this operation will be billed tome at the address identified above as the IICCOVNTAttpREss for this site. I also certify that <br /> all 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 SPATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to we or my representative: <br /> APPLICANT NAME(PLEASE PRINT) �#C,t/1 ���t,-1 SIGNnt'uRE �J�,,, <br /> TITLE 'ID# 6T— 0-3 5 Lf 6r.>6 <br /> Approved sr Oats Accounting Oflkoe Processing ComPtated ByOat+ <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT it CHECK# RECEIVED BY WORK PLAN PE <br /> ��t/� t <br /> FEE:$ f-3i".00 %IIetIt, c/' 3z Y`/ t(/ iy <br />