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Sanfkquin County Environmental Health Dellpment <br /> a n GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION &LOP <br /> UNIT IV <br /> CASES <br /> �rtas,Fda�EHD vu DNLr owNERIDIF <br /> OWNER FILE:COAIFLETE 7HEFOLLow7NGPROPERTY OWNER/Nrol 77l faeC0ry OWNER QfRAYiR ymmEA END <br /> PwaERIYOANeINAam U• q l (mei �- 1,,1 <br /> Firers Mf Last PNDNEMMe91 <br /> EMYLAwi Ess <br /> guestassNNeE urn`s f}ti"t<i K frr <br /> owwrHameMdrase <br /> CRY STATE IN <br /> owner NelllROAildreele //a'!S S. <br /> MR"Address,I amre -P SZ�tc <br /> GDRPWhleTKIN❑ INDNIDtNL❑ PAIeTNFAEIaP❑ FMA,011 of <br /> SIT!Mnnolme 10N_EIMRown Ewl ASSESMIll_VOLUNTARY CLIll_WATEA QUAIJTY—.HW PIPELINE NhenTOATON_LOP_ <br /> FACILm IDR IIrAf AccouerlD PORS±RO# ASSY31e EF&LOYEE LE a AOENDY:EHD___RWQCB_DTSC_EPA_ <br /> Fplob2ltb 7(j'9 SzJOO — <br /> FACILrTY FILE 00vFLE7E THE alnil/NO BUSINESS 11-10111 SITE/H-l7IOM <br /> Is this a NEW SWIM"LOCATION ratprevluualy regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes No ❑ <br /> Is this an EKIBTING Sslalnal IACATON but NEW TYPE Of rl <br /> eRllaMUehd Blel Yes ❑ NO <br /> &MNFS'YFAORAYf&MNaME e f✓)J >�LIV 'I✓ <br /> ISIONE <br /> 8"ADDRESS ?Oct <br /> IY <br /> I S- AV,1611., 5'r�•f' Gam' - -lrx. <br /> Lill <br /> DffY SPATE ZW 0..l L^'W <br /> �adc�p, Cly- K� <br /> EwRooFSul>ERVIwRDmrnlCr Lorwnal CODE KEM NEY2 <br /> INI Addlase MLV9:EREA(l FBONYAdb'ea+ Adlenbla:MV—W Of(*l <br /> al <br /> STATE IP <br /> Mail Adtlresa City <br /> &CCDDE All (bMIBlU <br /> THIRD PARTY BILLING INFO: Complete N Biging Party is diKerent from Property owner orFil lily Operator idenGfiedabove. <br /> Adwt <br /> EIMME6e NAME bm WCAre Of A*01±efJ <br /> /✓CcvJ I <br /> Mal" pu� <br /> AltllRM :S Li� l��±f 1/'L 2�l'✓'v'• PZ2-/ � -3W U � <br /> Cm STATE 7Jp � /(✓� <br /> 5t,ll CA <br /> Ap 4R»feea and ChargesOWNER FACII.ITY1BU$INES$ THIRD PARTY BILLING <br /> JrfC CO ACsn M" T: I,theandersignd Applicame certify thatI em the Owner,Operator,.,Amamkrd Agmsl this Eusineu,eedleckn.wledge that all PakWTFtPS, <br /> PENdO=ENPDHee WCIGP4Cfaadbr RODR[vClGx ssamwaa wonthis operation,will N billed to meat theaddreas idemi&daboveas the Actor/ATAMpGfffor the lite.1s1mcertifythat <br /> sit information provided o.thu.,diatal is the and curseeb lead that all creeletd activities wiR be performed in scc.dm with anan appGmbk SAN JOAQUds CoOrcn Ordinance Codm nal <br /> Standards and STATE aadfor Feneau.Lams and ftsdatioas.As the undanipld owner,op.rater,m,legml of Joe Property totaled M the above feditylshe address,I hereby autb.iue the relin..f <br /> ley and all realla end mviro.memal measmal information to SAN JOAQUIN COUNTY EN VLRONMENTAL HEALTS DEPARTMENT an moo as it h available and at the same San it e <br /> provided tANTNAME(Pi.mtstive. <br /> APPLICANT NAME IPLFASEPNNf) 01� &OWiT�E S� ,ff�rCC �)TlUYn <br /> TITLE blj. .Aer TA%IDA <br /> Dar. llllllal <br /> ORE..P,viceea a Dina <br /> :11 i all: masll: <br /> SITEMI1310 IdI AMOUMll, DATEOF MYYEIR PAYMafT7YPE REcvPTR CHECKN RECaVFD Rf WDRKPUN PE <br /> FEE <br />