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San Joaquin County Environmental Health Department <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION&LOP <br /> tireDEl!AREAD rOe ENO use ONLY OWNER IDI CAGE o UNIT IV <br /> .OWNER FILE:CohrPLETEPROPERTY OWNER!RESPONSIBLE PARTY INFORMATION.' Cmecxir OWNER CuxAFNrLYONFAf mwN EHO(� <br /> PROPERTY OWNER NAME 1' rl t� i` ) '( Irl i• 10 <br /> --- Frrs7 !MI teal PNONe NuxeeR <br /> BUSINESS NAMEt J E-MAIL ADDRESS <br /> • � r�,►.I J' I c+ 1 I,LI( l `3, 1°1 ;" _ 1 1 � f_ c i (- I �E.�r`�;{,� �r�- -f- <br /> Owner Hurls Address <br /> _ t�i1 <br /> City c STATE <br /> Owner Mailing Address - — <br /> Mailing Address City .State ZIP <br /> ❑CORPORATION ❑INDIVIDUAL U PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSMLE PARTY ❑OTHER <br /> SITE MITIGATION ENvtRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVE3TIOATiON__LOP - <br /> FACILITY IDX INV* AccouNT ID PR V RO g A33MMEo EMPLoYEE LEAs AoENCY:EHD_RWQCB DTSO—EPA_ <br /> I Fi <br /> � (rn hu €yt <br /> FACILITY FILE: COMPLETE BUSINESS I SITE/PROJECT INFORMATION• <br /> 13 this a NEW Project LOCATION not previously regulated by the ENVIRONMENTAL HEALTH OEPARTMENT7 Yes ❑ No U <br /> Is this an EXISTING Project LOCATION but a NEW SCOPE OF WORK? Yes 0. No ❑ .m <br /> BuswESS1FAcwTY1StTE/PRWEcT NAME < l K <br /> SITE AoonEes I PROJECT LOCATION ' 1 SURE N BUSINESS PHONE <br /> V '•.l I l i I I N ' <br /> City <br /> r-), <br /> STATE ZIP r <br /> r <br /> SS q ,Z�( <br /> BOARD OP SUPERVISOR DISTRICT M LOCATION COOS O KEY1 LKEY2 <br /> Mailing Address IfD/FFERENrfrom F&cOifyAddroas Attention:orCare Of(opllaul) <br /> Mailing Address City STATE Zip <br /> SIC CoOE APN 0 COMMEXr. <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orResponsible Party identified above. <br /> BusiNEss NAME ,y k ^t �! -rf-r✓ I Attention:or Caro Of (optlonal) <br /> Mailing Address \� ` r PHONE ';1--17�/2-0 <br /> Cm )-1 067 STATE ZIP –( G• <br /> r ONO t' <br /> ArxaMr VzWF-SS for fees and chargesOWNS FACILITY/BUSINESS IRD PARTY BILLING <br /> DR I.IVG AVD Osyt.l l"T1 At KrniY1-I:DG�yiF�"Z; 1,the under iEnul AppGculr,rernh ),at I evil the(A+'r+ter.OJxnrinr, lu/(iariZrrl Akrrr(,tx Re-'r thla 14 end i Meknaarird at�1)/rrRfr(t FE'f't, <br /> f'tA,u.imi,E.I tox(l.IIL'Yr cium,F.T.indlor 1101.'N.r OlAxtits"satiated wilh this Projcrl,rig be billed In nee al the ndd—t idt,'dO ed Above as the&I.r +,tT lis site. 1,1139 certify Ilan aD <br /> Information pro0drd an this Applltatlon is trite Alii torrent:and that all retillatni artiviltes MD hn,performed to accurJance pith allppliuble SAN JOAQVIN COt NTY Onliaante Cates atRltor <br /> Standatils Anti StATx andr9r Ft omni.I.eats,-.rid Re;ulntian. As die 9ttdct,ic—d 0---r,01—olo1,luih9tiled 4eeo4 or Reslumsihle Pt y for Ilse pru}ect locnled nbore mobil facility/site address,t <br /> hereby outhurue the release of any and all rvuJis,rcpurts,and other cns'li onnienul nssmnient infurrrmtiitin to SIN JOAUI'I,Y COUNTY '%'IR0XMFNTAL I`H DEPAR-1 MFNr-s soon as h <br /> I%A—ilable and at the sonic time it is prntided to me or ear rrprisrntanA r. <br /> ( APPLICANT NAME(PLEASE PRdtr) 1/ < ��l S .NAruRs <br /> TITLE �• (7 � .jP ��L�H �� t7� TAX ID 0 <br /> t .._ _ { - - <br /> Approved By Unto A-1111ng Office Processing ComPlsttd By Data <br /> SITE MITIGATION /AMOUNT PAID DATL OF PAYMENT PAYMLHT TYPE i RLCF.IPT r CI/ECK d RECEIVED BY WpRK ftrN PE <br /> FEF: \Nt <br />