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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATE7/17/13 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION& LOP <br /> = — Ofterig t 3 �� DAtE,S�xao9G UNIT IV <br /> OWNER FILE;COMPLETE PROPERTY OWNER/REBPONSI <br /> BILE <br /> 'PARTY INFORMATION: oxcar,►OJ-Mm <br /> cbwRewnrwvRAeNrrN EHD� <br /> PRavLmr OMTaER NAaE GIS ix �e-vl rli (261) J3 . 033 <br /> Fmsr ul Wr <br /> PIatME Nt1YtER <br /> ButFIESa NAaE Em ire. 1: 41 E5i-A I-e.- L i w y co a1,Go, LD1,.. <br /> OwaEA Hoare Arx aEas <br /> CRT <br /> STATE ZIPDWIrtR MALMO AIIIIgEN 102'} Easf Al ins- vc . <br /> MAIIINOAINM "CRY <br /> eTAT111A z" 95205 <br /> SSI ATpN ❑MIMAUUAL ❑PARIROteHP 13OM'ER41hoci A0ER0YI�,.�^ <br /> ❑REaPON6101.E PARTY ❑ORWi <br /> SITE MITIGATION ENVIAOa rE AL ASSESS MENT_VO LU NTARY CL CAN U P_WATER QUALI TY_HW PIPEL I N E INVESTIGATION_LOP_ <br /> FAOAJry iD�l� IlaAft AOOOUM ID ROt AeeaNEO CtaPLOTEE Luo ADOIcr:EHO_RWOOB_DTSO,[EPA_ <br /> .S 2*7 3 40 I'L �bwA• <br /> FACILITY FILE:COMPLEM BUIMNESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJEDT LOCATOR B$PMEVIODELY REGULATED BY THE ENVIRONMENTAL HEALTH DEPAsTmEfin YES ❑ N0�41 <br /> IS THIS AN E%ISTIINI PMMWLOCA700K BUT A NEWBCOPE OFWORN? YES No O <br /> BVAAEDWFACtf1YlSRFJ►Yp�pT YIt� <br /> ol-wm -ea " — kPF ac1l� <br /> Bf1E ADDREsal PROIFOTLOOATYI SufEt B4{alEtt PHOME <br /> Gz4 P—ask Alpilit, Av� <br /> cm Cys`kms K ,LA STATE zP �5•�0 5 <br /> BOAROOFBUPBIVOMmtRIttl 107— LODATIOM CODE Q / NEVI Keg <br /> MAariO AogtE"�PaiHigI�OM FAMYADDIEAA ATrEaITION:ORCARE OF(cprA>we) <br /> MAIINO ADDttEee Cm <br /> STATE $ <br /> 81C COce APN t <br /> //7-v a(w <br /> THI RID PARTY BI LLI NG INFO:COMPLETE IFBILLINGPARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PAM IDENTIFIED ABOVE, <br /> BIIaMEIca NATE �e�h — NaIiOnal L• ATTENTION:MCARE OF rOf'T'M'LAL/ <br /> MALxa AO —,s- <br /> 5(-5 i { lT v-enL.Le I fbu--�4,- :Floor FRS 212 .$85.1(oZ9 <br /> Cm W-eu my, <br /> AxaDNTAODRMTOEENOFFFESANDCIWaE9; OWNERO FACILITY/BUSINESSI] THIRD PARTY BILLING <br /> Riu.Inn AW CQUINJANCEncxvmv \ 1,the undersigned Applicant,terlffY lWl I am the Ower,0,Nwer.AupmrludAynm,ar Respuasaf,Pvrry end l acknowledge llvlall Pexin FEAq <br /> Px\'ALOM,£.\PORC84E\TGURCE[and/or froc."C""W ea"Cated"Iff INs P111-1 will be billed In me ac the address Nentilled abmr as the A=U\TAnoAUKG for INS lib.1 No certify that it <br /> Information provided on Ibis Application h true Aad C..i;Aad that all ,,fed aAIIYllies X111 be performed In accordsrN,wIIh all applicabb SAN JOAQUIN COUNTY ORDmae'cv.COnas All, <br /> ST.\RDARDS and STATE.and/or FEDERAL Una and W.n;LATIMY.AA the underslgand Own,.ORerumy AmtredrdARML dr Rca ooniibfe Parry for the project lamed Above under feeilipfslte Address,l <br /> hrreby Authq(rn the release of Anr And SII rNvba,reports,end qhm envirenmenml assnsment Informetlon ID SAN JOAOVIN COL'NTV EasntOBa 'WM.IIRAt Of i 'PA1OMMENrvS soon ss It N a"If.ble <br /> Rodin the AAme time U,providetlmme orr/myrepresentathee./ <br /> At'PLpANTNAatE(PIEAAEPRAR) <br /> 239 ° 7 — <br /> 2 ° <br /> ARWIOV®m IL\rE AMURRPXIOOacEPMTAaaRpCOWaETmEy OAre a3 <br /> 81TeY TqN ATaouNr PAID DATE OF PAYaaFJTT IAYeIEMTypE REOEIPTt OHEONt REOETfE0 BY W PIAN PE <br /> Pee;tny 'jos �ul.y l� ZOI CFlECK 3°`l18 / LlouA+(�j �(� <br />