San Joaquin County Environmentat Health Department
<br /> DATE MASTER rlLE RECORDWFORMAMN 'gMFR'f GREEN FORM
<br /> -ITE MITIGATION&LOP
<br /> SHIhOk'n—EA',FOP fD40 iisr Mice oviNvi ID11 ok) 00-/& CA UNIT IV
<br /> 0-VVNER FILE-Coul.,tF-rE PRO PUR T-Y—OWN ER/RESPONSIB Lf--PAM ljvFoRAfA Tom, C14ECK Ir OWNER 0Vqr-r)VTLYV4 frit F W17H FHD
<br /> IlRoi,Ef;,Tv OMER NAME
<br /> ClUtIVERS I-l-P,,E
<br /> t
<br /> Owner Homo A&jmt�
<br /> A
<br /> -Ij L v
<br /> City
<br /> STATE, ZIP
<br /> Owner Malling Addru3v
<br /> Malling Addr000 City its ?IP
<br /> ❑ 1014 El INOIVIDUAL U PArTNFRSHill ❑GOVERIJ1.41114T Aaclicy ❑Rrtmouslw,fr PARV 17 OTHCR
<br /> sil C NlrrlGk,rloli EuvtRoMMEN-TAL ASSESSRICNT VOLLTUTAll Y CLLARUP WATER QUALITY MV PIPELINE INVESTIGA ION_LOP
<br /> V--
<br /> D P 1 i A,siamm EmpLoYEE QC 5 DT80
<br /> FACILITY ID N Inve AccouisT I LCAvAGENcY.,El4D_Rw, EPA—
<br /> n I R j��r/ i, I�,�.; ,.;
<br /> FACILITY FILE: 0CMPLErE BUSINESS/SIT El V€04r--0T mroimm TjoA"
<br /> I,-this a t4cw Praject LOCATIOm,not prevIOUSly rei]31112tedby the ENVIRONMENTAL MEP.Mi DEPARTMENT? YES El No 0
<br /> is this an CXISTIPIG Project LOCATION but,a NEW SCOPE OF WORK? Yrs d i,,io Cl
<br /> Sr-,Amuss/PROJECT LOCATION J OuTTEN BUSINESS PHO146
<br /> STATE jj zip
<br /> Z-4-
<br /> Eavisor DISTRICT L.CATI..CODE KEY I KEY'
<br /> thalling Addrasn ffD1rpcRrNrfrom r'acilifyAddross AttenLlow vrCam Of(optlonGl)
<br /> Mr.illnjg Address City 3TATr zip
<br /> l9IC7c0DE APN COMMIrM
<br /> Tmiro PARTY BILLING INFO: COMP10te if billing Party isdifferent fromProlperty Owner orResponsible Party irlaidiflodabove.
<br /> BUSINESS NAME f k
<br /> Attention:orCare Of (optional)
<br /> filailling Address�.—1 PHONE
<br /> Z
<br /> OX.
<br /> .':TATE. Zip
<br /> for fees and charges OwNER)
<br /> FACILITY/BUSINESS D PARTY MI-LING',)_
<br /> v krPIi,.a-11(,--,iI,dot I ; 0m,"
<br /> PLNALFIL1,E.,mlaxIxYr an-flor "idl fl.i, tifl Im,h0r.i fo u,L.M tl,e qs ii.m all
<br /> forimiliw V-,t,wIcd na this qlpliollmo is fnze",ld e-,,ii:,ftj([,;It all rrLulawd wip-wie-k :0 h, ul I TOAQUV;fot,l 1,0,dill.111,(:njj,s nmli..
<br /> t 11 1
<br /> ti-I Op, Autti.,"i-eJ of ll�,)mn,ibll I-A)1!1,11:�,, e
<br /> ;lwhanLt IllercluscolmIX t.4 o!iakoi ly uoj!lTv I I H DLVAII if
<br /> nt(he Some rilm i;i,provided mm,
<br /> APPLI CANT NAME(PI.rAsr.P N It If) _f--
<br /> v 'I ATU;;[:
<br /> T�TLC II !
<br /> L
<br /> L�-,ppmvod Sy flrooe--.Inlj Cxlvfl.tvd�sv U.I..
<br /> .................................
<br /> LI ef9nit•:.rrotlt Am., 0AI E Cl;� i IM4HIlk'Ill R1GrNF7SIT 1 M01,1:
<br /> ;Z940
<br />
|