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/ <br /> San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> 1=::� SITE MITIGATION&LOP <br /> 914AQEOAREAS FOR EHD usEONLY OWNERID# CASE# UNIT IV <br /> JL3b ILA k <br /> OWNER FILE:COhfPLETETHEFOLLOWINGPROPERTYOWNERINFORMATION.' CRECX/FOWNER CURREmnyoArFrcemn+EHO <br /> PROPERTY OWNER NAME AI��� fs,( // <br /> .Oki n 1 \ <br /> First A41 fast PHONENUMDER <br /> E-MAIL AODRESs <br /> BUSINESS NAME <br /> Owner Homo Address <br /> QvS�: A 044 <br /> city SPATE <br /> R; an CA <br /> (honer Mailing Address <br /> dlrvlc a5 a.boJ <br /> Mailing Address City sl ,� Slate Zip <br /> CORPORATIONA INDIVIDUAL[:] PARTNERSHIP❑ FED AGENCY El �❑ <br /> SITE MITIGATION_ENVIRONMENTAL A33"$MCNT_VOLUNTARY CLEANUP_WATr-R QUALJTY_HW PipEuNe INvesTIGATION_LOP_ <br /> FACILITY ID# INV# AccouNTID PR#IRO`# ASSIGNED EMPLOYEE LEAD AoENcY:EHD_RWQCB_DTSC_EPA <br /> _ <br /> 0 322 14 S`l <br /> FACILITY FILE COMPLETE THEFOLLOWNG BUSINESS/FACILITY/SITE INFORMATION: <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEI No ❑ <br /> Is this an ExISTING Business LOCATION testa NEW TYPE of regulated Business? YES ❑ No ❑ <br /> BusINEssT`ACIUTfISrTE NAME <br /> S�T^ oa S:NC55 Q.1"r <br /> SITEADDRESS I SUITE# BUSINESS PHONE S <br /> CrTY STATE LP <br /> CA-. <br /> 95-366695-366R" o <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE KEY1 KEY2 L <br /> Mailing Address N0IFFERENTrromFacl/RyAddress Attention:orCare Of(apUonal) <br /> Sec awns T-r,�o <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN# CotaMFM: <br /> aagd9oo '9 <br /> THIRD PARTY BILLING INFO: Complele if Billing Party is different from Property Owner or Facility Operator idenliTed above. <br /> BUSINESS NAMET Att`nUon:orCare Of(o nal) <br /> AU v� �OaGi J "VI PSS 0. ?,f'S LIZ <br /> �n� YT1t)S <br /> MRIIIngAddresa PHON Qq �� <br /> 5O Cher Lo )e 5U%--1-e l o80 <br /> STATE ZIP <br /> CITY <br /> qS33 <br /> A==EA4nREss for fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> nii.I.INO,r Nn COeIPLLINCE ACANOWLEnGSIENT: 1,the undersigned Applicnnt,certify that I am the Olrner,0peramq or Anrhoriwd Agenr of this ousloms,and I acknowledge Ilia(all PE&wr FEES, <br /> PGv,I1,T1ES,EN£ORCErEATCNARGET and/or HOUREr C/IARGFS associated with this operation,vlU he billed tome at the address Identified above ra the AffnunT,tnoxecc for tills site.1 also certify dint <br /> all information provided on this application Is true and correct;and that all regulated acthitics,rill be performed In acc-dnuce with all npPlkoble Su+JDAc351 COUNTS'Ordinance Codes andfor <br /> Standards and SPATE and/or FEDERAL Laws and Regelother. As the undersigned owner,operator,or agent of the prspe <br /> rt located al the abo• ladillry•/rile 6ddrW, hereby au Woriu tiIc rctcnsc of <br /> any and all results and environmental assessment lnformntiaa to SAN JOAQUIN COUNTY ENV <br /> IRONMF,NTAL IIE.\LT❑DE TAt /,Is soon as R is m• Iahlc and at the same time it i< <br /> provided to me or my representative. <br /> — <br /> APPLICANT NAME(PLEASE PRINT) SIGNATURE� � � � ����,yt;� <br /> TAx ID it / <br /> TITLE j Cl j f1- 2('— 6 G <br /> Accounting Office Processing Completed By Dols <br /> Apprnwd By Dab - <br /> SITE MITIOATION AMOUNT PAID DATe OP PAYMENT PAYMENTTYPE RECEIPT# Co,:n RECEIVED BY WGRxPUNPE <br /> FEE; <br /> obs t <br /> CONFIDENTIAL <br />