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_ San 1quin County Environmental Health0partment DATE11 1 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM SITE MITIGATION&LOP SHADED AREAL FOR EHO USE ONLY OWNER ID# CASE# UNIT IV OWNER FILE:COMPLETE THEFOLLOWING PROPERTY OWNER/NFORMAT/ON: CHECK IF OWNER CURREWcyowFILE WITH EHD� PROPERTY OWNER NAME / \ First Ml Last \PHONE NUMBER BUSINESS NAME E-MAIL ADDRESS Owner Home Address City STATE ZIP Owner Mailing Address Mailing Address City state Zip CORPORATION El INDWIDUAL❑ PARTNERSHIP El FED AGENCY❑ OTHER 11 SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP FAcILM 10# INV# AccouNTID PR#/RO# FACILITYFILE CoMPLETETHEFoLLowNGBUSINESS/FACILITY/SITE INFORMAnoN: Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No ❑ Is this an EXISTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ BUSINEsisIFACILIY/Sne NAME SnEi ADDREss SUITE Is BUSINESS PHONE DIY STATE ZIP BOARD OF SUPENVaoq Charmar LOCATION CODE KEYT KEY2 Mailing Adthe aa if DIFFEREW grow JeeciiityAddresa Attention:orCare Of(options/JJ Mailing Address City STATE LP SICOODE =1 APN# COMMENT: TNIIto PARTY BILLING INFO- Complete if Billing Party is diRerent from Property Owner or Facility Operator identifiedabove. BUSINESS NAME Attention:or Care Of (opttonzal) Mailing Address PHONE CITY STATE LP AccaRwZADOBES6 for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING BILLING AND COMPLIANCE ACKNOwLEUCMKNT: 1,the undersigned Applicant,certify that I am the Owner,Opemiar,or Authorized Agent of this Business,and 1 acknowledge that all PERMIT feFs, PEN4LT,',ENFORCE wC✓uROET and/or RouuyCHwsaes associated with th a operation will be billed to meal the address Identified above as the AcrOUHrADDR£ss far this site.I also certify that all Information provided on this applkadon is true and correct and that as regulated aetivides will be Performed in accordance with all applicable SAN JOAQusN COUNTY Ordinance Codes and/or Standards and STATE and/or FEDERAL Laws and Regulations. As the undessigaed owner,operator,or agent of the property located at the above facility/site address,1 hereby authorbe the release of 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 itis provided to me or my representative. APPLICANT NAME(PLEASE PRINT) SIGNATURE TITLE TAX ID# Approved By Onto Acocunt ng Office Processing Completed By Data SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY wogN PIAN�PFE+` FEE:;