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r <br /> San Juin County Environmental Health aartment <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION &LOP <br /> BHAoeo AREAS D EHDUSEONV ONMER ID# CASE# UNIT IV <br /> OWNER FILEXOMPLETE THEFOLLOWING PROPERTY OWNER INFORMATION: CHECK IF OWNER CURREWTLYoNFREWm1 EHD El <br /> PROPERTY OWNER NAME ( > <br /> First MI Last PHONE NUMBER <br /> BuslNess NAME E•MAILADORESS <br /> Owner Home Address <br /> city STATE LP <br /> Owner Melling Address <br /> Mailing Address City state Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> $ITE MMOAT10N_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILm 10 It INV# AccouNT ID PR A/RO# yr Ci�V.� Y <br /> 4 w Lfi ii IfTE t._`V l <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS I FACILITY I SITE INFORMATION, <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ <br /> Is this an ExIsnNG Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BustaiessIFAMLITYISITE NAME <br /> SREADDRENS SUITE# BUSINESS PHONE <br /> CRY STATE ZIP <br /> BOARD OF SUPERVISOR DISTmCT LOCATION CODE KEY1 KEr2 <br /> Mailing Address HOIFFPRENrfron,FaclllfyAndras. Attention:m,Care Of(optional) <br /> Meiling Address City STATE LP <br /> SIC CODE APN# COMMFM: <br /> THIRD PARTY BLLLINO INFO: Complete if Billing Party is different from Property Owner or Facility Operator ident(fredabove. <br /> BUSINESS NAME Attention:OrCare Of (optional) <br /> Mailing Address PHONE <br /> Cm STATE ZIP <br /> Accotwr9gQHFSS for fees and charges OWNER FACIuTy/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: f,the undersigned Applicant,certify that I am the Owner,Openah r,or Authorized Agent of this Business,and 1 acknowledge that all PER F¢ , <br /> PENALTw,ENFORCemewr CrdlRC,FS and/or HOURLYCRAR6Es associated with this operation will be billed to me at the address Identified above as the A ccouWADDRimi for this elle.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 sailor <br /> Standards and STATE and/or FEDERAL Lam and Regolatiom. As the undersigned owner,operator,or agent of the property looted at the above facility/site address,1 hereby audrorice the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a it is available and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAX ID <br /> Approved By Date Accounting Office Processing Completed By Dabt <br /> �µ <br /> SITE MITIGATION AMOUNT PAID DATE OF PAVMEM t7l�� <br /> CXECK# RECENED BY . 4, P.+i f.., <br /> FEE:$ afi <br />