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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> SRAgi,,t) RID#AResa roR EHO usg ONty OWNER CASE# UNIT IV <br /> OWNER FILE:COMPLETET/IEFOLLOW/NG PROPERTY OWNER INFORMATION. CHEcxiFOWNER CORRENnYOAFFIcEwirmEHDn <br /> PROPOMOWNERNAME At b"4— cchl n. ( ) ---I A <br /> Lasl PHONE NUMBER <br /> ` E-MAILADDRE33 <br /> BusINESSNAME 416e,4 CG{')� �` '� C. --- <br /> Owner Homo Address <br /> RoQa - <br /> city STATE ZIP 9.366 <br /> R� ari c� <br /> Owner Mailing Address <br /> __ �jaryi4. a5 a.ba✓C ---- <br /> Mailing Address City I SLde j ZIP <br /> N C <br /> CORPoRATONA INDIVIDUAL❑ <br /> PARTNrRSIIIP❑ FEDA(;FxcY❑ 011I'cR❑ <br /> SIT!MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINL INVESTIGATION_LOP <br /> R._._ -- <br /> FACIUTYID# INV# ACCOU!ITIp PR#1R0# ASSIGNED EMPLOYEE LEADADENCY:EHD_ <br /> FACILITY FILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOcAnoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEI <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ <br /> 8USINEss1FACIUT`llSrrE NAME <br /> 5�� oa S:k,-e!56 cid"r <br /> SUITE <br /> SITE ADOREss <br /> 19O s. s -, ROad <br /> Cm p STATE <br /> I� o h C J2 <br /> BOARD OF SUPERVISOR DISTRICT 1-2 <br /> ON CODEKEY1 KEYL <br /> Malting Address/fO/FFERENTbomFac1111yAddrsss p Attention:orCare Of(op[lonal/ <br /> Sec aw>r-T�-� T " <br /> STATE ZIP <br /> Mailing Address City <br /> SICCOOE AEN# — -----II COMMENr: <br /> -- 7:1 <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner or Facility Operator identired above. <br /> BUsmss NAME r� ,I Q� T Attention:or Care Of(, nol) <br /> RU vT Q.OoLd J lVie55 o sol— �In: mus <br /> Mailing Address PHON <br /> 50 Chert- LL�T..T,e St„-� I oq Sad- 080 <br /> STATE ZIP <br /> CIT[ S-- <br /> AGGBLWAIppHE89 forfoos and Charges OWNER FACILITY/BuSINESS THIRD PARTY BI011..moomm� <br /> LLING <br /> DlLi.wr,AND COMPLUNCE ACKNOWI—mG IENT: 1,the undersigned Applicant,certify that 1 am the Owner,Operator,or.luthori:ed'Agent of this Business,slid 1 aclmowleJ{;e 11,31 all 1+ER1flT FEES, <br /> PEV.rLTIES,LC.VFORCEIIEATCII.IRGET and/or 110ORLs•CRARGES assodalad with this operation will be billed to me at the address Identified above m the.IrrnmvTdsaxF.cc for tilts site.I also certlry that <br /> all Information provided on this application is true and earteer and that all regulated activities will be prrfarmell In accnrdnncc with All nppllcAbte SAN JOA COUNTY Ordinance Codes and/or <br /> Standards sad STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the property located at the abo))•r faeilltyhite 6ddrtss, hereby aunmriTC the rdensc of <br /> any and nil results and environmental assessment Informallon to SAN dOAQU1N COUNTY ENVIRONMENTAL IIEALTII DE�TAI lVl"v sooD¢s it 137 <br /> s av table and at the some lime It is <br /> provided to me or my representathe. / <br /> --�� SIGNATURE <br /> APPLICANT NAME(PLEASE PRINT) o t 1 tryl <br /> TAX ID# t f <br /> TITLE 3� G <br /> Approved By <br /> Bab LFAcwwunung ORlce Processing Completed By coloSITEMITIOATION AMOUNT PAID DATE OP PAYMENT ENT TYPE RECEIPTS CHECK# RECEIVED BY WORKPLANPE <br /> FEE-$ <br />