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San Joaquin County Environmental Health Department <br /> DATE // MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> / 6 2oi1 SITE MITIGATION& LOP <br /> D� <br /> H rAe EHD O OWNER IDX CARE# j�tjyg5 UNIT IV <br /> OWNER FILE:COMPLETE THEFOLLOW/NG PROPERTY OWNER INFFORNMA TIO ,- CHEciuv OWNER\CuRaetorcroR £ rR <br /> rnnrEND El <br /> PROPERWOWNERNAME S� Ile / <br /> ) ( / <br /> First MI Last PHONENUMEER <br /> eUBINES9 NAME • EMAILADDRESS <br /> Owner Name Address <br /> citySTATE ZIP <br /> S,�1r,L• (:;4Gov ./ / A 9Szv2 <br /> Owner Meiling Address 6�a ' CR 1f► I /4 Verl tat 0, o4l <br /> Mailing Address City State <br /> Lov{; <br /> CORPOMTION❑ INDIVIDUAL❑ PARTNENSHIPA FED AGENCY❑ OTHER❑ <br /> Bring MITIGATION_ENVIRommaNTAL ASSESSMENT_VOLUNTARY <br /> CLEANUP WATLR QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDX INV# AccoUNTID PR RDA ASSIGNED EMPLOYEE LEAD AGENCY:EHD_RWOCB_OTSC_EPA_ <br /> IS3l <br /> ;2L,3(,5- 2-4 Yb (o <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SITE INFORMATIOM- <br /> Is this a NEW Business LOCATION not pre rlously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IM <br /> i ` <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No 51 <br /> BIMINEBWFACILITY/SITENAME Fla 6/ eAe,N- <br /> �J n / SURE# BUSINESSPHONE <br /> S ns ADDRESS 6Yxl (4/Jlo/ /coati <br /> Care 44 <br /> ZIP <br /> G4 91"292 <br /> BOARDOFSUPERVISOfl DISTRICT LOCATION CODE KEY1 KEYZ <br /> Melling Address Ife1FFERENToOrn Fao///tyAddroea Attention:orCare Of(oprbna/J <br /> STATE ZIP <br /> Melling Address City <br /> SIC CODE 11 APNN COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner OFFacility Operator identified above. <br /> BuslNEss NAME Attention:orCare Of(Opf/Ona/J <br /> Mailing Address PHONE <br /> 9W /�tCor✓✓<Ae � �•><e N eSiU);L71-Y7-co <br /> STATE ZIP <br /> CRY / -A 91"9,19 <br /> G�c.Ts cis/ <br /> c=UYYrgtJORESS for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE AC O\VLEDC:NIENT: 1,The undersigned AppllcanL certify that 1 am the o,vner,Operator,or A.11ni ivif A£ON of this Business,and I Acknowledge that all PERAUTF££5, <br /> P£Nitrrrs,FNFCRCP(FN'T CHARGES And/or Noeur Civ iaGES associated will,this operation will be bitted to air at the address identified above as TDe A=1wrADDIIGte for this site. I also certify that <br /> all information provided on this applicaden Is true and correct;and that all regulated adMiles Will be performed In aecoNmtce with all 11PIAICatde SAN JOAQUIN COUInY Ordinance Codes and/or <br /> SemWnrds Ans STATE and/or FEDEMu Laws and RCgulations. As the undersigned owner,openter,or Agent arthe property located at the above racility/site address,l hereby Authentic elm release or <br /> nm•and all results and emdmmeental nssersmau information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it h available and aT the sane time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) 6 r fol 114r �f-••1- v Pir SIGNATURE <br /> TAx ID# � <br /> TITLEPro W h p Q/ A <br /> SffEMMGAMj0N <br /> Deb AAaoum m,00i Praaeeaine Complebd Dy Dela G/ <br /> AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPT# CHECK# RECEIVED BY WORKPLANPE <br />