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0 • <br /> San Joaquin County Environmental Health Department <br /> DATE p l J l I' do I I MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHA09P REASPORE"OUNE9111.1 OWNERli CASEM UNIT IV <br /> OWNER FILE:COMPLETETHEFOLLOWINO PROPERTYOWNER/NFORmil7iow . CREarfF OWNER CYRREWLYCNF/LEWITHEHD❑ <br /> PRaPErmOWNER NAME K; wet I kc if ca 93 - SSl <br /> Flat MI Last PHONE NumEs <br /> BUage"s NAMEE-WILAODREW <br /> C; KI e,) @e.• foekhJln.�a. e <br /> 'Owner Home Atddreu <br /> 'F/ G�JAdo ROOVA <br /> tatty ZIP <br /> Suck <br /> STATE <br /> 7,5962- IM <br /> Owner Meiling Address <br /> Melling Address City Siete Zip <br /> CORPCR-TION❑ INDIVIDUAL❑ PARTNERSHIP 11 FEU AGENCY El OTHER® <br /> SITE MITIGATION_ENVIRONMENTAL Asng$MENT VOLUNTARY CLPANUP_WATER QUALITY_NW PIPELINE INVFATIOATION_LOP <br /> FACILITY IDR MVM AODODaTID PR#f RO# As,10NED EMPLOYEE LEAD AaENcYI EHO_RWOCB_OTSCEPA_ <br /> o b R 5 31& <br /> FACILITY FILE COMPLETE THEFOLLOW/NO BUSINESS/FACILITY I SITE lwotit ATIoN' <br /> Is this a NEWBusiness LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 9 <br /> IS this an FVSTING Business LOCATION but a NEWTVPE of regulated Business? YES ❑ No ❑ <br /> BUNNEdeIFACILNYISMNAMEl <br /> L COVICf 10 tjd. I ?,r'Felrhj <br /> ( S O �� ( SUITE# BUEIN; ,AXONE <br /> SDE ADDRESS I7Q I S. � 141 � VV iV ✓! <br /> Cm STATE ZIP <br /> S1acK}av� c 520 6 <br /> BOAROOFSUPERVISORDICTIRIOT LOCATIONCODE RhYT REY2 <br /> Melling Address l/O/FFERENT(rovnFao/lkyA Z'9 Attention:orCere Of(optional) <br /> u N• F Da s - c1 C <br /> Mailing Address City /kckIT" TATE ZIP <br /> S 7fJ I� o a <br /> SIC CODE APN M I 101�_O ILD_ I� COMMENT: <br /> THIRD PARTY BILLINO INFO! Complete if Billing Party Is different from Property Owner orFacillty Operator identified above. <br /> \ BUeNESSNAME ECa o Attention:orCere Of(optioru9 <br /> \ —Inv ✓an Hf ✓cfl a 1 <br /> �\ Melling Address pHol <br /> 19yv 01Os ✓ St✓ee� Sti/fe )o0 5lo .�dq .(o 76 c <br /> Crtv STATE LP <br /> o4kl4�d <br /> A000uNrAOOeaeP for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILUN <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: L the undersigned Applicant'artily that I am the Owner,operator,or Authorued Agent of this Business,and I acknowledge that all P£RMIT FEE$ <br /> P£NALRES,ENhVRCEMENTCHARO£Sand/er HOURLYCRGESassoci-W With this Operationwill htbilled to meet IMaddra!identified.havem rheACTU!/M'AOUFES.S for IhY 1110. Islas eerdfy Ihal <br /> all information provided an this epphado.is true and correct;and Met all regulated wetivides will be performed in mcmdana with all appgcabk SAN JOAQUIN COUNTY Ordinance Coda and/or <br /> Shndard,and STATE and/or FEDERAL Law,and Reguladom. Aa the undersigned owner,operetory or agent of the property lacamd at the above facility/site eddrea,l hereby aulhorke the releae of <br /> say and all r..WN and environmental aaaament information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as anon r it u available and at the lame lane it is <br /> provided to me or my representative. �l' <br /> APPLICANT NAME(PLEASE PRINT) ,ylq lG l ) pgll l' SIGNATURE L/_iLA/•7 <br /> TITLE J_ TAX ID# <br /> 5 ylio Geo a l s <br /> Approved 9Y Can, Accounting Mae Processing Complebd By Oats <br /> SITE MITIOATION AMOUNT PgIo DATE OF PAYMEM PAYMENT TYPE RECEIPT# CHECK <br /> /M RECEIVED BY WORK PIAN PE <br />