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San J•quin County Environmental Health 10artment <br /> 66MFR" <br /> GREEN FORM <br /> DATE MASTER FILE RECORD INFORMATION MFR <br /> E "(i �: .J I _ SITE MITIGATION& LOP <br /> SHAM ARIIAM EHD DB Owmat IDE 4# UNIT IV <br /> OWNER FILL I00AIP[E7FTHEFO[LON?MO PROPERTY ER/NFORAfA77ON: <br /> f.7ENT•OTYNER G&MMISMYmFXerrrw END❑ <br /> PRONarvowlan NAME ( ) o - -- <br /> Fbst Ml Last ADEM~a <br /> r ra o� <br /> Gwner Hone Audra <br /> BTAIE Lv <br /> CRY o n <br /> owner railing Addrew 3 515 lla�1�0.v\ 2 l:A s ro.� aL. <br /> MI Address CRY C,�a-c�o�2 ��IC. ztv Z8a <br /> MtsMouAL❑ PNrrIEfaMtIP❑ FEo Aaosor❑ OMER❑ <br /> CaRaoRAnor�''// ENVAA,, <br /> SITE MITIGATION 0.ENVIRONMENTAL ASSESS O"_VOLUNTARY CLEANUP_WATEIt QUAIJTYip HW PIPIUM INvigirn"TwN_LOP <br /> FACKIY-IDS INVS Account lD PR S/ROf AesSaxED ErPLorEE L.EIIDAaENCY:EHD_RWQCB_DTSC_EPA_ <br /> FACILITYFIN t C06'"`TB TNEFOLInwmGBUSINESS/FACILITY/SITE/NFORI770N- <br /> Is this a NEW Buskma LOCATWH not Previously ragulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No Ii�yi <br /> Is this an EXUMNG Bualness LOCATION but a NEW TYPE of regulated Business? Yes ❑ No yy <br /> 6IreEWFACILMY1511E NATE <br /> SRE Aoor 2 Y\eY (t -1t - <br /> STATE zP <br /> `a" -.3tDL Tr \sr 1, Cif q52) S <br /> BOARe Dr BUPameoR DtsrWcr LOCAncel CODE I(Efi I(EYZ <br /> MW"Address fOfFFEREArrfw FiaWAdsws Attention:o Care Of(OPMNW) <br /> I�Address DRY STATE ZIP <br /> sic CODE APNS Contort: <br /> TNIRD PARTY BILUNG INFO' Complete it Billing Party is differ--'---Property Owner ot-FacilityOperator identified above. \ 1 <br /> BtINKEM MASE Atbanti :orCve Of(0010011d) QYtY\ J?lA�rl <br /> ��raeK c\\{ _j <br /> Malang Addwe jOoS 3r�' v 1 • �IOb- 4-11 — 4)-?,? <br /> CITYc� r srAlE Ir <br /> C. Z D Z <br /> AcigailatrAOaam for fees and chargee OWNER FACILITYBUSINESS THIRD PARTY BILLING <br /> Ein LING ND COMPLIANCE ACENOWLED mEPTI I,the undersigned Applicant,certify that I am=r r Operator,or AWtoriwd Agent of this Business,an a PER,%7TF= <br /> PENALIIFB,ENPoaCPMFMCNAFGESAnd/or NOUAEr CnA st associated with this operation will be billed tome at the address identified above as theACCOfor this site. 1 also certify that <br /> all information provided on this application Is one and correct;and that ell regulated activities will be performed in accordance with all applicable SM JOA(yMi Cro Ordinance Codes and/or <br /> Standards and STATE and/or FEDEwu.Laws and Regulations. As the undersigned owns,operation,or agent of the property located at the above facility/site address,I hereby authodae the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as so it is available a at the same time it is <br /> provided to me or my representative. I� <br /> APPLICANT NAME(PSEwee PINK" V� ��'�/bL-�yl BlaxAnlRE <br /> TIRETAX IDA 5— 3. It <br /> OJ �D <br /> rii R. <br /> ore <br /> ons. ora <br /> SrrErnKusT AMOUNT PAID DATE M PAYMENT PAYNBNTTYPE REeevrs CNECKP RECENIED BY WORK PSAN PE <br /> FEE: <br />