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San Joaquin County Environmental Health Department <br /> rg dd GREEN FORM <br /> DATE j ��t 2�i — MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> a06Irt UNIT IV <br /> �B�>Lox_� oYnlmllx D"°er52D04S1 CP <br /> Cfarosr OWNER gYfaEATLrwvreelRrNENb <br /> OWNER FILE 3COMPLEM TNEFOLLOWNO PROPERTY OWNER/NFORA1A7701W I)d . I <br /> PBpvenvOVOMNAM ) nia Jr2 —�-I 3D <br /> MI Last �� <br /> First _ <br /> BtRAEaeNAae S \� DALC7r @ JI P.•lAA" <br /> o,nu rHorn,Addnaa <br /> BTATII y <br /> Clly <br /> OWW MWNnB Addlwamp <br /> MMWq Addfan City G'f�0.r\O'(Le. W(✓ 20Z <br /> COPPOa,Tpl, aallouAL❑ <br /> PABIRHtMaP❑ FeoAIENm❑ oDEB❑ <br /> INTa MIT IOATION/Y-ENV rM&U TAL ASSM MIXT_VOLUNTARY CLEANUP_WATER QUALriY(d NW PINUNa INwTN1ATY�ION_LOP <br /> FAOtlL1Y IDT INH AtxouxT <br /> ID PR (7L7� As /Vl l orTa LuoAmar.EHD_RWOCBJy_.OTBC_EPA_ <br /> o 3683 ao4 Vl <br /> rACILITYFlLE CoMPLErETHEFOulDwAAGBUSINESSIFACILITYISITE/NFORAunaN: <br /> Is this a NEW BusNleaa LOCATION not pr9iimnly rsauIeW by the ENVIR01drENTALHEALTHDEPARTMENT? YE;❑ Now A�y <br /> Is thi <br /> s an DBBnNO Buaklesa LtBG71oN tRA a NEIYTYPE of Tabulated Buagleas? <br /> YES ❑ No L1I <br /> aotinnilli NATE 5 11 ('A D� <br /> ./� IglBrer BLOOE PHaE <br /> \N- w T,la'Y Nit. SWTATe u S� -1 sZ) ssetvlsDR DUTtaBT <br /> 2 LOCATM NCOBE N6V1 � <br /> MA OU Add""KOffiEWArrhm/FAoWjPAolf'o°a AUwNom:OrCaro 0/(optlarWt <br /> STATE ZF <br /> NtdWlO Adtltaaa CRY <br /> 81CCOBE Ai tq!,vo-o7 Ooms . _ <br /> O <br /> THIRD pAtaY OIwNO INFO. Complete if BIII Party is different from P rty Owner orFi lyll Operator idenblled aboveC. <br /> BtpNEaa NATE b AeK AUattbtc erc.re tN loPdIwWJ QdtY� SAVOY <br /> Mwx'°Ad"w 1o6'5 -K P xE r,bb_ 4 21- 4 wA <br /> m <br /> fXn �cLS Game Z D z- <br /> IOOOIMrfAagTBlforfeaaand tsllarbaa OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> B �A XN DB ar' I,the undersigned Applicant,oertify that l am the Ouster,Opnmor,or AurNodud.lgrnr of ihb Business,an e • PeasnTFefs, <br /> PEVALrrE$E.vPoAfEAICAT ClEtuefs and/or HOUA4T(,N,IW J'assacialed with this operation will be billed to me at the address Identified above as the ACCODATADORW for this she.I also terrify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with ell applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATS and/or FEDEAL Laws and Regulations.As the undersigned owner,operator.or agent of the property located at the above fedllty/site address.I hereby authorize the release of <br /> Any and oil results and environmental assessment Information to SAN JOAQUIN COUNTY ENVIRONMENTAL: DEPARTMENT as toes 11 Is available a at the same rime it is <br /> provided to me or my representative. \ fI <br /> APPLICANT NAME(Pt Pw ) BlauTusE <br /> ` <br /> TAX IDk 61510 <br /> 3-� <br /> TITLE <br /> OaIA Z 7. <br /> 0aM OA 0' <br /> BRE MRaaTION AYOVM PAID DATEOPPAYMENT PAVMeITTYPE REM" CNEORr PEceIYEaev WBRGR P/,IRAN PE <br /> FEE:; l7 <br />