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San J juin County Environmental Health C ..%rtment <br /> DATE z_ , 2 MASTER BILE RECORD INFORMATION "MSR" GREENFORM <br /> p�� (SITE MITIGATION&LOP <br /> SkAmp Awl As FOREHDUSE ONLY OWNER ID* CASE*(r_ / /'� J�� -UNI ■ IV <br /> OVMER FILE:C0AAPLETE 7iltEFOLLO1ffNG PROPERTY OWNER hwoRMA710N.' 1/vCYn1 Ecx(F OWNER Ctm svrtf�roNFSEwmr EHO <br /> PROPERTY OWNER NAME fAlc 'NEL M ET- A <br /> First M1 Last PHONE NumsER <br /> BustNEss NAME EMAIL ADOREss <br /> i2 K &'Z Diel - AL- <br /> Owner <br /> LOwner Home Address <br /> 110 itl' 013 RPAd �77- 2-01 <br /> CRYATE zip <br /> LO <br /> 0 <br /> rLa S C-810S ST� 73P� 5 v3o <br /> Owner Mailing Address <br /> wo A 1) 0 r-z© <br /> Malftng Address Cfty Z-©S K,,4 T1251 <br /> state 2i <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHERN. <br /> SITE MiTwmm ENvimmuENTAL ASSESSMENT_VOLUNTARY CLEANUP WATER QUAuTY HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITtID* INV* AccouNTID PR*iROfP I AssIGNEDEMPLOYEE <br /> LEAD ACENCY:EH _RWQCB_DTSC_EPA_ <br /> FACILITY FILE COMPLETE THEFOLLOWNG BUSINESS I FACILITY I SITE INFORMA770N.' <br /> Is this a NEW Business LocA new not previously regulated by the ENMONmIxrAL HEALTH DEPARTMENT? YES ❑ No'14, <br /> Is this an EXISnNG Business LocAT1oN but a NEw TYPE of regulated Business? YES ❑ No <br /> HuswEssIFAcxjf JSRE NAME <br /> -LGS^ <br /> SrTEAoa+Ess SunE* ausINEsSPHONE <br /> i 1 1<O ' _ ^� A/&• M ANT— <br /> Cm STATE ZIP <br /> MAN CA C,4 gSSS3 <br /> BOARD o7F SUPERvisoR DmTmar LOCATION Com KEY1 KEPI <br /> eMairilg Address tTQ/FFFRENTIrorn FecilityAddress Attention.orCare Of(apbkvw# <br /> Mating Address City (� STATE ZtP <br /> fifo k,SiCCooE APN*�17'G2_O�� CoMatExr• .✓. 1 <br /> TmRo PAKTr BILuNis INEo: Complete if Billing Party is different from Property Owner orFacility Operator identffedabove. <br /> BuSNMNAME — A fzDdi-:jP-S 4 A S 5o . Attention:orCare Of(optiarAnf) <br /> S <br /> ung Address PHONE <br /> i SLS /Z(l>t2S'lt�� r�R 7,:2 Z-93 -z36 <br /> "Y STATE ZIP <br /> di�te5 EAVORESS for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLJNG <br /> 81LLLYG ANDCOmpLLAL cE ACKT70WLEDCSIENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operafnr,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT FEES, <br /> PEm,tL7TFS,EAPORCEuFJYrC11ARGES andlor I10UR7.r CHA/tGEV associated with this operation will be billed tome at the address identified above as the ACCOUNTADPRE_4S far this site. 1 also certify that <br /> all information provkled on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COU,"N OrdinanceCodes and/or <br /> Standards and STATE 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 /> IMV and all r,•sults and environmental assessment information to SAY.IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided tame or my representative. <br /> O <br /> APPLICANT NAME(PLFASEPRINT) /�FL�� ;/i J L Fog Ck A SIGNATURE <br /> TrFLE I // 44CC l 1 ,r TAX ID# <br /> ST - Gc=OL0/ i ffSS 7(, <br /> Apprnred BY Date Accmntirg Office Processing Completed By Date <br /> SrZ MnIGATiON AMou NT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPY C CHECK# RECEIVED BY WORK PIAN PE <br /> Ftr:,4 <br />