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R <br /> San . juin County Environmental Health9artment <br /> DATE MASTER FILE RECORD INFORMATION "MFRfe GREEN FORM <br /> SITE MITIGATION &LOP <br /> SHADEO AREAS FOR END USE ONLY OWNER 100 CASE# UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOww PROPERTY OWNER/NFORMATzoN: CHEcN IF OWNER CURRENTLYOwFW,6WM END <br /> PROPERTY OWNER NAME <br /> Fsst MI Last PHONENUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> Owner Home Address <br /> City STATE Zip <br /> Owner Mailing Address <br /> Mailing Address City Stets Zip <br /> CORPORATION El INDIVIDUAL El PARTNERSHIP L1 FEDAGENDY❑ OTHER❑ <br /> SITE MITmATON_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_IHW PIPELINE INVESTIGATION_LOP <br /> FACIUTYID# INV# LCOUNT IO PR#I ROME fK3� ? � <br /> '�?ar"r� ev�:s Irl k f s y ii t I S <br /> 11 <br /> FACILITYFILE COMPLETETHEFOLLOw/NGBUSINESS/FACILITY ISITE/NFORMAw <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 /> BUSINESSIFACILITYISITE NAME <br /> SITE ADDRESS SURE# BUSINESS PHONE <br /> Crry STATE hP <br /> BOARD OF SUPeRVMOR DISTRICT LOCATION CODE KE" KEY2 <br /> Mailing Addreaa ifDIFFEREA7rrom facility Address Attention:orCare,Of(optional) <br /> Mailing Address City STATE 7JP <br /> SICCODE APNB CokMENT: <br /> TNIftD PARTY BILLING INFO: Complete)f Billing Party is different from Property Owner or Facility Operator idenUfiedabove. <br /> BUSINESS NAME Attention:orCars Of (optional) <br /> Mailing Address PHONE <br /> Crr STATE zip <br /> A2dtt�s for fees and charges OWNER FACILrrY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMFUANLa ACKNOV/LEDGMEW: f,the Undersigned Applicant;certify that I am the Owner,Operator,er Authorised Agent of this Business,and 1 acknowledge that all PER FE , <br /> PENALTIES,ENFORcExrrATCHARGFs and/or ROURLYCHARGEs associated with this operation will be billed to meat the address Identified above u theArcof ADDRRss for this site.I also cerdry 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 COUNT'Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the und,.ig.d owner,operator,or agent or the properly lactated at the above faciBtyialte address,1 hereby audlorim 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 me or my reprmenladve. <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE <br /> TITLE TAX ID# <br /> proved By Data Aecounena Office Processing Completed By Dale-- <br /> SITE <br /> abSITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPE RECEIPT if CHECKS RECENEO BY UORk PawN P .�_� <br /> FEE:$ <br />