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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 />