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San Jon County Environmental Health D rtment <br /> DATE 3 - 2 ^ 20i( MA,;a R FILE RECORD INFORMATION "MV GREENFORM j <br /> SITE MITIGATION & LOP <br /> SNUOE I <br /> OWNER ID# CASE# UNIT IV <br /> OWNER FILE:CONLI <br /> MPLETE THEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON.• CNECKIF OWNER CuwnenrcronnLEWIM EHD� <br /> PROPERTY OWNER NAME W, LeG LWl1 ALf_ up,M,taand I <br /> TT TT (4oz) st{4 -6826 <br /> First MI Last PHONE NUMBER <br /> BUSINESS NAME L/ D <br /> Union PAL;}l(� �Qll� E-MgILADDRE99 <br /> Owner Home Address L.FFAM H ONDC�U P,Co N <br /> city <br /> SrgTe ZIv <br /> Owner Melling Address 1460 b6 'ay S-I-fstG� STOP )O3Q <br /> Melling Address City - I <br /> ornA V- state ZIP . <br /> �J NE 681`7?-t03o <br /> CORPORATION Ld INDIWDUAL❑ PARTNERSHIP El <br /> FEp AGENCY❑ OTHER El i <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT ✓VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION _ <br /> _LOP <br /> FACILITY ID# 1Nv# Aci:ounr lD - PRM/RD# ASSIGNED EMPLOYEE . LEADAGENCV:EHD_RWQC9_pTSC_EPA- <br /> RRDD19b$S PA05 \5525 <br /> FACILITYFILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMAT/ON.• <br /> ISthis 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? El <br /> YES ❑ No ❑ <br /> BU91NE991FACILIT'/SITENAME . 1niOn OSI/t(, p flrD,.d _ Ru-r <br /> V I •F FLl PTI, PL,r�,a.s� <br /> SITE ADDRESS F,r -/- 0�/(� ill <br /> ` 1 <br /> IOOO ` A-4 1`4IT I ill M P $S•66 Dak4�ad Su�(p• SUITE# BUSINESS PHONE <br /> CITY <br /> FrencGt L I1 STATE ZIP <br /> ?S 231 <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY'I - <br /> NEY2 <br /> Mailing Addrass"IFF£RENThwnFecl/HyAddrme - <br /> 400 Lt, n,. (' STop 3U Attention:wCaza Of(opNona9 <br /> Meiling Address City W' I" L <br /> —&M 16426 <br /> DMdlta STATE ZIP <br /> NE 68178 - 1030 <br /> SIC CODE APN# - - COMMENT: - <br /> THIRD PARTY BALING INro: Comp/etc if Billing Party is diSerentfrom property In Or Facility Operator identified above. <br /> BD$INEa9 NAME I <br /> Coy �ss�l. fG Attention:orCare (olazlIc <br /> Meiling Address / �' I ((�+t <br /> S V I'l a PHONE <br /> tv --y 20 -0-7 00 <br /> CITY TT I <br /> Gr✓1 V 1`hL STATE ZIP u <br /> ACQQlAVL 9DBZW for fees and charges OWNER FACILITY/BUSINESS <br /> THIRD PARTY BILLING ✓ <br /> B16LINr AND FO CEA C'A G WL De E I,the undersigned Applicant,certify that I am the Owner,Operatoq or Anl/ton¢ed Agent of this Business,and I acknowledge that all PFaMn'Ners, <br /> PENnformaENeprovide TIC this ap"and/oon is true and carrGRI ct;"i-fell with this nyeration will be billed to me at the address identified above as theACe00NTADDRFSS for this sih. I also cerli(y that <br /> SII information provided on this application is true and correct;and that all regulated activities will he performed in accordance with all applicable SAN JOAQUIN COONIY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent ofthe property located at the above hadlity/site address,I hereby authorize the release of <br /> any vad all --Its and environmental aazzasmcrt information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same fruit is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) RrpN SCFPEF G SIGNATURE <br /> TITLE c P• �Ya .r TAX ID# <br /> J S� i�la�na�er CRA <br /> A provetl By DA[o Accoun9n Once Procoaain Com IatetlB <br /> SITE MITIGgT10N AMOUNT Pg10 DATE OFP YMENT _ Dala � p ( <br /> FEE: PAYMENT TYPE RECEIPT# DHEDR# RECEIVED BY WORN PLAN PE' .at`� <br />