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0 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NFORM <br /> DATE 7/17/13 MASTER FILE RECORD INFORMATION"MFR" <br /> SITE MITIGATION&LOP <br /> o�y A� DMS omm IM UNIT IV <br /> CNEORpdFtvEa le CwRENfLf wYfA.EwrtN EHD <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: l/ 4 <br /> PROPERTY owxER NAA6 G� q„Y $CYI n i 20 1) 33 033 <br /> Furst IRI Usr PxaFE NVIEm <br /> BueFEEE NAFE r m 'ice Real GS{�� i cot a�Do, urt�.. <br /> ON HIM!ADDREINS <br /> STATE ze <br /> Cm <br /> OYAILR IAALMD AIwREEE 16” Ea,Sf Alpine- Avn . <br /> MAA.NOADDREN Cm 541 � +ovs, STATES A 95205 <br /> �CDRTA TION Elwon cou ❑P urimatEHP ❑OOdERNYtNTAOENOT (3RESPONeICa1LECrE PARTY 1 ❑orXfR <br /> SITE MITIGATION K.ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP_ <br /> FACIA.m lot ItN/ ADcoDMT ID PRNRO# AEEaxeo EFIPLDYEE LUDAD w:EHD--JtWQCB_DTSO,[,EPA_ <br /> IP HN <br /> FACILITY FILE:COMPLETE BUSINESS I SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NII PREVIOUSLY REOVLATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? yes NO NO� <br /> IS THIS AN EIDSTINO PROJECT LOCATION.BUT A NEWSCOPE OF WORN? VES µr No ❑ <br /> BVEMEEA/FAOEITYISREJPRDKDTNAre oJ,_Yn"C �L(,F-fn — kPF Quli <br /> Surtef BIMIFIFEEPHaIE <br /> SDE AIRMEEE I PROJECT LOO AmM <br /> X24 Ea54- I Iht v� <br /> Cm Sy�Lk,{,e� G/(1 STATE 952-05 <br /> �I`"' U 2 LDw.TaN Coce O ( NEY1 NEYz <br /> DDARo of BIPERWECR DtEIR1OT <br /> IAAIVID AOOPENIFDEFERENT FROM FAcam•AomEAE ATTEMTaN:gTCAREOF(APTNM ) <br /> STATE ZIP <br /> AIAAJMD ADDREEA Cm <br /> 81C CODE APNE CDIIIFERF' <br /> THIRD PARTY BILLING INFO:COMPLETE IF BIW NG PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> ATrEBTON:MCARE OF(A'rTAANAL) <br /> BIIANEE6 NATE <br /> fCea-e-VA - ' <br /> MAAJIJo AW N Fi 1-17 v-entre- , +:Du-r4-k Floor BE 212.885.Ito29 <br /> Cm N� `{orl� BTAE zP X001'1 <br /> ATxOVNT ADORFJIE TO SFNDFEES ANDCNMO®: OW NERD <br /> FACILITVIBUSINESSD THIRD PARK BILLING <br /> (' a FAS'avno' fIX'Mfrr: Ltbe undersigned APplisenl.fcrtlsy lhAlibe ille le eOt[be d„ludmdud ANanAmRr'he Arblr Parry AnREMfor Wssil llvtl All eOir)TFEST, <br /> l'N.\'ALT1hS.l_.1'FORfBVE\T(/lAfl4'£S PrINOr//O f'RI.Y LII.IRLRJ'ASSCCIO(MI With Ihli prn,Ml N1111C IIIICd In mC tl11hC AdSIfC[5 hifnllpfd P11P'C AS'he.1 Cf04:\Tr10nNPSS for Ih15 51(C. I,l v.C.ou,IINI eH <br /> Information Provided An Ihil upplicutlon Is true vnd correct:And Ihnl All INONe1l ucllrlliss x511 be performed In ACcnrdnnce Wlth all Applicable SAH JnAoutH Cou>"n'OAmn,�'ce.Cones vnNor <br /> StsSnanns vnJ SrAre And/or F'ePEnnt.LnWS And RT.Cmmlov.N the Anderslgnm(harm.Oprrumr.dupmnud AA'rn/,Ar Re Pnn.dble Page for the pre,al tccwcl Abm'e Ander fncflity/sits Addrnr.I <br /> hsreby nathwim Ihs rtleuse of vny Antl vll rfsnlD,rry�ons,enJ a@er envirunmemnl vssevsmmn InlarmmlOn to Sns JOAOLI.v C(U": F.]\•111;ON '11AL IIC.V.TII I eAmweYT ex smn vs It Is AVAIIAhIe <br /> AndmthesSnlc time It is pro.'Idedw,reermyrepraenl.ths. / <br /> APPLICAMT NATE cPlEwee PRM, SLG�/7(v l ! /l� /!J f'( / 1��i• Bt0/IA._ Tune <br /> PE— <br /> PS <br /> mE J� r�AxlD/✓//3(r - 23g2�07 <br /> AREd!®9Y d•TE <br /> AWd/R101C OR10E P0.0QlMWCOWIFIEDOY MlC <br /> BRE MmD.ATIDM AMODMTPAU) DATE OF PAYYEM PAYNEHTTYPE RECE" CHECK0 RECENEO BY WORIj?GT <br /> FEE:{ /%` V <br />