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San J4uiri County Environmental Health Dt, <br /> _.rtment.. <br /> s I <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> 'i SITE MITIGATION& LOP <br /> SHADED AREAS FOR EBD_UYOWNER 10# l 0 CASE# .5'100 L <br /> �- UNIT IV <br /> OWNER FILE:CDMPLETE rHEr o[LoWNG PROPERTY OWNER lwoRMArlon+• ;t CHEcWff OWNER CURREMLYON FILE wim END <br /> I PROPERTY OWNER NAME <br /> 3at, X Z 610 <br /> First M/ LastI <br /> a - PHONENUMBER <br /> BUSINESS NAME r <br /> ESI CQt.I'FI! E�MAILADDRESS <br /> +V ItCr G R S LT II <br /> Owner Home Address <br /> 1311 G _TMPE0L1A%_ jf1C.HwjW <br /> city <br /> STATE ZIP i <br /> �; 0 <br /> Owner Mailing Address ` i CAr Qc)G 7 <br /> 1311 iMyE11,►pt... 1i�1G4iWALi <br /> Nlaphlg Address City stafte Zip <br /> p 6`10 <br /> CORPORATION❑ INDIVIDUAL© PARTNERSHIP❑ �1 f FED AGENCY❑ OTHER <br /> SITE MITIGATION_ENYIRONIMENTAL ASSEMMP,NT XVOLUNYARY CLEANUP`WATER QUALITY_NW PIPWNE[wim "inoN LOP <br /> Fac1uTYID# INv# AccouNTID PR#f R0# ASSIGNEUEMPLoYEEA <br /> LEaDAQENcY EHD r`RWQCB DTSC2EPA <br /> M I <br /> _. I <br /> i <br /> FACILITY FILE COMPLETETHEFOLLOWING BUSINESS I FACILITY SITE/NFOROA7700W11 <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT?': YES CI NO .❑ <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? IL YES © No ❑ <br /> SUSINEsBfFACILRYiSITE NAME $ S1 C4Q .1UiA- 6'+S L-IV3. _p" { <br /> N 141 <br /> SITEADDRESS �+ -1 SUITE# BUSINESSPHONE <br /> NDKIft WIL.SaN Wh if <br /> Cm S `� C 1 I STATE ZIP <br /> -toC. <br /> T n1 c� R 2 1505- <br /> t <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEYS i KEYz _ <br /> MailhV Address KDIFFERENTheanr FaaflityAddress I Attantlgt:cwCare Of(opdornel) <br /> Mailing Address City } STATE ZIP <br /> I <br /> SICCODE APN# 1? 3 idp / COMMENT: <br /> - <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFkility Operator identified above. <br /> BUSINESS NAME Ii Attention:orCare Of Apffoml) <br /> i 4 <br /> MallhtgAddress I,[ I PHONE <br /> CITY It STATE ZIP <br /> I <br /> AccouNTAppEESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that 1 am the Ower,Operator,or Aadforized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PmAtmES,ExroRCEMEAT CHARGES and/or HOURI.YCHARCEs associated with this operation will be billed tome at the address identified-above as the ACCOUNTADDRES.S 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 STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property ilocated at'the above facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME as sfon as it is available and at the some time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) �MO� �(s pr SIGNATURE <br /> } <br /> TITLE <br /> TAX ID# <br /> P��J itc,1 �I�� 1 C) Eos - 6s2 y <br /> Approved By Date Accounting Office Processing Completed B <br /> SITEMITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK RECEIVED BY WORK PLAN PE.,; - <br /> FEE:$ = . <br /> ,k <br />