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r ! (;F.IE <br /> San Joaquin County Environmental Health Department APR 10 2012 <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> vti los 1� <br /> SITE, 1 iRRiEALTH <br /> $ EHO SEO OWNER ID# 17iv � S2mGV75 <br /> CASEY NTMI RVICES <br /> 5 <br /> OWNER FILE.COMPLETE THE FOLLOW/NQ PROPERTY OWN ER INFORMA Tfox., CxreArw OWNER CuaarxnrammEXnx EHD� <br /> PROPERTYaww"IAME z i, �t�—_�—1—1 ' <br /> NrrQ Fiat Mf Lest PHONE NuMeER ( 1 1� -1-77 <br /> BUMNEWNAME ^' n EMNLAnciam <br /> IvrSvJ L,. t J � CA 1 Ll ` rr%escnAA 1/Tf,rIziAfAC<j ar-\ <br /> Omer Hams Address <br /> J A <br /> city STATE LP <br /> N rT <br /> OMTner MaNing Address <br /> P,o, 6sox 16q 0 <br /> Malting Address Cily p� State� �S�O 1 C( Ln <br /> DmPGRATON❑ INorvIouAL❑ PARTNERSHIP❑ FEOAOENCY❑ OTHER0 L1r, <br /> 917E I ITIGATION—ENVIRONMENTAL ASSEUMINT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION—LOP_ <br /> ,P-Iu23S FACIW ID It INVY AccoumID3T34T M/ONEET LEwoAaENcr:EHD�RWDCB_OTBC_EPA_ <br /> FACILITYFILE COMPLETE THEFOLLOW/NO BUSINESS/FACILITY/SSI ITE INFORMATION., <br /> Is this a NEW Business LOCATION notprevlously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ Na <br /> Is this an ExISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> aa31NES51FACILIIYl.9lfE NANTE <br /> nNt' fcY:wc�J 1NC.- <br /> BTTEAOORESS n BurtEY atuiNeas PIaNE <br /> Cm {.fCA�•IJ sCTrA ?IP (3530 <br /> BOMGOF SUPEniVISOR DISTPICT Oy LocnitoNCooE UV KEr1 KEr2 ��11 <br /> Meghrg Address ffD1FFERSVrfiOcnAcWAddt%AAs, AtBmtlm:orCare Of/optlata/1 <br /> ,o 00y, I Qo 2.T. Nou <br /> Melling Clb, Cw 01S"o I� STATE ZIP <br /> �y7-owl- <br /> SICCOOE APNY H COMMENT: <br /> THIRD PARTY BILLING INFO.' Complete if Billing Party is different from Praperty Owner orFacility Operator idenAriedabove. <br /> BUSINESSNAME N 0 I ^ Affention:crOam Of(OPeeIK/i <br /> Mafing Addreee �} PHONE <br /> Cm STATE AP <br /> Acmue2AenREss for fees and chargee OWNER FACIUTYIBUSINESS THIRD PARTY BILLING <br /> BILLINf.ANUCOUPLTARCEACRNOWLEM,%IEM': I,theundersignc!A iraat,e that lam We OxmeqOPPm(M,orAinhodRd Agent of lids Busim.,end lackm,1Nge lhxt all PEftUR 1}'E1, <br /> PENALi/ET,ENrilWE4i,.WoIAN.rvandfur frooa6r Ciiow.Lsassoulated wilhl k operation will he billed to me at the address identified above AS theAMMnAnnREss forthhsile. lalmeertifyflat <br /> oil information provided nn Misapplication Is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN Joeoum C'oONry Ordinance Codes andfor <br /> Standards and STATEaalfor FEOEML Laws and Regulation. As the undmigned owner,operator,or agent ofthe property located at the above fadiity/site Address,l hereby aulhorke the relme of <br /> any and all results and enHronmental assess <br /> ment information to SAN.IOAQ.U1f1N COUNTY ENWRONNUENTAL HEALTII DP.PAR tMENT as soon as it is aver le xnJ ul the sxme time it is <br /> providedlomeormyrepresentatke. ��JSps'N t.nrl -C1h-MHI � t-L I, <br /> APPLICANT NAME(PLEASE PRINT) (v NJ(,iJ � �«I SIGNATURE <br /> TITLE �lr�yMU-4 _ 1�•. TAX ID q 7 <br /> ovad6 Data Aaoountl ONba Pr000aa Com MfeditDale �J I� <br /> rFEE: <br /> lMITIe<GA/TTION AMO�jUNT PAID DATE OP PAYMENT PAYMENT TYPE RECEIPTY CX�E]r.XP �j RecEIVEOSY WORK(JPUN PE <br /> $ J /S )�� y-ra-rzS� <br />