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• <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SHADE))AREAS FOR EHQyn gp&y OWNERID# CASE IN UNIT IV <br /> OWNER FILE WOMPLETETHEFOLLOWING PROPERTYOWNER INFoRMArtoN: CHEexIF OWNER CURREHTLYOHFlLEH7TH EHD <br /> PROPERTY OWNER NAME }f-CQ(�y: 1 n �yn &I,1 I • <br /> -- _ -- Vw►ac RICA X369-4341 <br /> First Ml Last PHONE NumeEFt <br /> BUSINESS NAME (l`�►�t _/tx{sy`� •cnat , <br /> /`.k'. Lcrd EMAIL ADDRESS <br /> In0'{t1 <br /> Owner Home Addre s <br /> - - - i b 6Id <br /> 21 ttiP.r- (yd (�hyit't�r► _ A( (�drng� Vn�(,rni l <br /> City STATE f`�SS`^w ZIP <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FEO AGENCY❑ 9-hj r OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT— OLUNTARY CLEANUP WATER QUALITY V HW PIPELINE INVESTIGATION_LOP <br /> FACILITY ID# }4Ftu:a' .sz++• xp�.x w2 q, r . ,*.. <br /> INv# AccouNTID PR#/RO# Aq EHDF211A YI <br /> Y 5 <br /> .::tom _ •%y r%; T�.��G n fie#f._'. � �!„.. �'�. <br /> FACILITY FILE COMPLETETHEFOLLOWING BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINESSIFACILITY/SrrE NAME C��K ^WS& ■tAVAsS <br /> SITE ADDRESS ^�O^�— S. <br /> A ` �� SUITE# BUSINESS PHONE <br /> IPOrSTATEZIP <br /> BOARD OF SUPERVISOR DISTRICT LOOATIoN CODE KEYS FKEY2 (�` <br /> Mail Ing Address ifO/FFERENT from Facility Address Attention:or Care Of(optional) <br /> I <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# COIMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME Attention:orCare Of (optional) <br /> Mailing Address PHONE <br /> Cm STATE 7jP <br /> Aes�uecrAass for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING A-No COM►LIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify that I am the Ower, r Agent of this Business,and I acknowledge that all PERMrr FEES, <br /> PE.YALr/Es,ENFoRCE.vE,wCHARGFS and/or IIovALYQr,IRGES associated with this operation will be trilled to me at the address Identified above is the ACCOC+NTAODREss for this site.I also certify that all <br /> information pro%;ded on this applIcation is true antl correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent or the property located at the above facillty/slte address,1 hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTbt ENT as"a as it is available and at the same time It is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) __�i1..� tfllL SIGNATURE t <br /> TITLE ��' n/�_ 111""" TAx I D#INA <br /> Approved By Det. Accounting Office Processing Completed By Date <br /> Srra MIl/TIooGA//T�I(,O.NI AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# i RECEIVEo BY WORK PtJIN Pi • ~ <br /> FEE:III <br /> "i1 J <br />