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San Joaquin County Environmental Health Department <br /> s DATE MASTER FILE RECORD INFORMATION"MFR" GREENFORPA <br /> go/2 SITE MITIGATION& LOP <br /> 8 A ONLY OWNER IDN GASES D yg3 <br /> UNIT IV <br /> i <br /> OWNER FILE:COMPLETE THEFOLLOWING PROPERTYOWNER INFORMATION.' CNecNtF OWN ER CNReNTLYONnt£WeN EHD <br /> PROPERTY OWNERNA (zo9)Y6�'T00a;a <br /> Fust MI Lad( PHONENUMBER <br /> T �O EMAILADDREBS <br /> BUSINEsSNAME SGn ✓Odi A+ �a..n Tt r /4��(.. A <br /> Owner Home Address <br /> /ilio EG,t yaTe Hoer Awe. <br /> sTCq z9Saof <br /> city <br /> Owner Mailing Address <br /> Mailing Address City State Zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP L1 FED AGEROY❑ OTHER <br /> SITE MinGAT1oN_ENvIRaNMlNTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER 0uALrrY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILRY IDN INvo ACCOUNTID PRIPRON ASSR3Nat EMPLOYEE LEAD AGENCY.EHD_RWQCB—DTSC_EPA_ <br /> X531 7 ,21, �6S 5L GLE <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS/FACILITYISITE INFORMATION.' <br /> Is this a NEW Business LOcATIoN not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an EAISTING Business LOCATION buts NEW TYPE ofregulated Business? YES ❑ No EO <br /> BUSINnWFACILm/Biw NAMEo- <br /> 91TEAOORE88 SUITEN BUSINESS PHONE <br /> 6y2/ lop./o/ Ro<at/ <br /> CITY STATE ZIP <br /> SAu 1/1'{oas CA 9f�/7F <br /> BOAROOFSUPERVISORDISmUCT LOCATION CODE KEYI KEY2 <br /> Melling Address NDIFFEREIdTrrom FaclNsyAddress Attention:orCare Of(opeonal) <br /> Mailing Address City STATE ZIP <br /> ' 91C CODE APNN CoaetENTo <br /> THIRD PARTY BILLING INFO: Complete ff Billing Party is different from Property Owner orFacillty Operator identifiedabove. <br /> BUSINem NAME Attention: rCore Of(optional) <br /> Mailing Address PHONEC5-3U, .T 7-2' 9200 <br /> 9YY !/<<o<../,T Rpt• Su:�� �{ <br /> CITY STATE ZIP <br /> ca w <br /> Aggg&M AooREs_s forfees and Charges OWNER FACILffYIBUSINESS THIRD PARTY BILLING <br /> SILLING AND r PLIAN ACRRO UC ENT: 1,the undersigned Appllcan,certify that I am the Oeuer.Operator,or i ed Agzed Agenruf this Business,and I acknowledge that all PER.wa Feet. <br /> PenaLr,Es,FNmRCENENr CMJRGEs AnW.r Houn VCHARGEE associated with this operation will be bitted to me at flue address identified above as tit AtrnnvT.IDnsess for this site. I also certify that <br /> all information provided on this application Is true and correct and that all regulated activities will be performed In accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Sbuulonds mW STATE and/or FEDEI Laws and RegWations. As the undersigned owner,operator,or agent of the property located at the above facilitylsite address,l hereby authorize the release of <br /> ony and all nsedls and emironnsental assessaw"I iefo'motion to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available nod at Ibe same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) cot I! M CT7Nt( SIGNATURE <br /> TITLEJ�]Jrd ,,ff//�I <br /> 1 tTAX ID It m_ <br /> rc C � o YLo 1l <br /> A rovadBffAmoumT <br /> Defy AccoanUne Omca Praceseing Compinted By Dab I <br /> SREMITMOATION DATE OF PAYMENT PAYMENTTYPE RECEIPT# �F(Fi <br /> RECEEIIVED BY WORLNtPIANPE <br /> FEE: t� f�� <br /> __ -- �qli <br />