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San Joaquin County Environmental Flealth Department <br /> DATE rly MASTER FILE RECORD INFORMATION f`MFR" GREEN FORM <br /> 7 [�e '/1A �(�. SITE MITIGATION&LOP <br /> BHAOeogRGlsrOREHO UaeOM.Y OWNER IDM GABEC_v D�y/_.F� UNI • IV <br /> OWNER FILE:COMPLETP THEFOLLOW/NG PROPERTYOWNER lwoRMATION: cNECxIF OWNER cuWHEWrerowFrzEwRN END � <br /> PROPEATYOWNERNAMe 'I/A <br /> E't I I <br /> First MI Last PHONE NUMBER <br /> BWINEw NAME EMAILADDREss <br /> Owner Home Addream <br /> city STATE zip <br /> iOwner Mailing Address/L' 79 /V A' ,� rM <br /> Mailing Address City ``T7 Steto C� Zip <br /> Q/ F� <br /> Ls <br /> CORPORATION❑ INDIVIDUALI$ PARTNERSHIP[] FED AGENCY❑ OTHER❑ <br /> SRl MITIGATati ENVIRONMINTAL AssmsmeNT_VOWNTARY CLEANUP—WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY IDs INV# AODDUNTID ASSIGNED PLOYEE LEAD AGENCY:EHD_RWOCB DTSC_EPA_ <br /> I �31 ab3�� "52?S�9G 0b _ <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SI E/NFORMAT/ON., <br /> Is this NEW Business LowioN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No Q' <br /> Is this an EXISTING Business LOCATION but NEW TYPE of regulated Business? YES ❑ No a <br /> BUSINEWFAciuwISRE NAME <br /> /7a 6 Cbev o <br /> SITEADUREss SUITE# BUSINESS PHONE <br /> 'I �Y/1/ <ayD,iIa/ /Neel <br /> Dm. STATE ZIP <br /> Slr,..410.. CA 9Sz9 <br /> BOARD OF SUPERVIKNIDIEria LOCATION CODE KE" HEYt <br /> Melling Address HO/FFERENTfrom Fsc//ityAddmas Attention:or Care Of(opfionsl) <br /> Melling Address City STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete If Billing Party is different from Property Owner orFacllity Operator identified above. <br /> Attention:arOare Of(oplionsig <br /> BUsINEwhiAue <br /> /hG SGNKe, 6�el V/r TaTC. <br /> Mailing AddressL PHONE <br /> r <br /> <fT o)171-vz� a <br /> CITY STATE ZIP <br /> BCCOUAT QUEESS for fees and charges OWNER FACILITY/BUSINESS HIRDPARTY BILLING <br /> 0 AND Con NCr ALIO+ a DI E T: I,the undersignnd Appliran4 certify that I am the Oamer,Operator,or rOnherized Agent of this Business,and I., n all PERmITFertS, <br /> P( ALT/ES,EHPORCLueW DIAab'ES amber Ho6'Rty CHd CES associated with this operation Mil be billed to me al the address idenlill above as the AcrMIYTADDREST Im this site. 1 also certify that <br /> all information provided on this applicadon Is true and correct;and that all regulated activities"rill be performed In accordance will.all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Lnws and RegWatinns. As the undersigned owsi opemmr,or agent of the property located at the slave facilityls'ite address,l hereby mdhosize the release of <br /> any incl all results ami envlemmer ml assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP.ARTRIENT ns soon as it is ovaibble and al Ilse sante time it is <br /> provided to me or my representnHve. <br /> APPLICANT NAME(PLEASE PRINT) 6r6J11ft M f SIGNATURE <br /> , <br /> TAX ID Ig 71 <br /> TITLE tj <br /> e LI N <br /> gde gate AacounBne Oman Proanselna Completed By Dole <br /> AMOUNT PAID DATE OF PAY9MEN/rT� PAYMENT TVP RECEIPT# CNECH# Re,even <br /> WORIf PLJA/N'/P/)E <br />