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0 9 <br /> San Joaquin County Environmental Health Department <br /> I DATE /� MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> $ p EHDU9_A ON OWNER ID# CASE#�`nM/ ub�/ UNIT fu <br /> OWNER FILE:COMPLETE THEFOLLOW/NO PROPERTYOWNER INFORMATION:LW 1 A IC(NEctin,OWNER ConAmor tyoxri eWiru EHD EJ <br /> PROPEATYOWNERNAME P <br /> First MI Last PHONENUMSER <br /> BUSINESS NAME EMAILADDI E98 <br /> Owner Home Addy <br /> city STATE Zip <br /> Owner Mailing Address <br /> Mailing Address City State ZIP <br /> COPPORATION� INDIVIDUAL❑ PARTNERSHIP El FEDAGENey❑ DINER❑ <br /> SITE MITIGATioN_ENvIRONMINTAL ASSESSMENT_VOLUNTARY CLIANUP_WATIR QUALITY HW PIPEUN!lRvl lT 'TION_LOP_ <br /> FACILITYID# INV# AccouNTID PR IR0# ABBIDNEO EMPLOYEE LEAD AGENCY:EHD_RWQCB_DTSC_EPA_ <br /> 40-T9 3�3 23 r <br /> FACILITY FILE COMPLETE THEFmtow NO BUSINESS/FACT IS E/NFORMAT/ON.• <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this anF icASTING Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ No ❑ <br /> SUsiN ScAUFACILITYISITENAME p� �, A <br /> SITEADnnaas $DITE# B#91NE99 PIiGNE <br /> CITY J L STATE ZIP <br /> BMRDGFSOptAV18OR DIBYHIGT LOCATIONCCDE KEPT K'AEYE <br /> Malling Addem"IFOIFFERENT#cm Fa011HYAddress Attention:orCare Of(optional) <br /> Mailing Address City STATE ZIP <br /> SIC CODE APN9 CoMMENY: <br /> Iyg0-+001 <br /> I <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> Bu9Iu nIs NAME 'Cubpt' Coo-Su.lKtwt3 Attention:orCata Of(op#unag <br /> Mailing Addre9s1111 G 1 v� - PNONE(�rb) 3�I r6A.O <br /> .TI } T' 4 <br /> S PTTS� ZIP <br /> CITY W at S'Aa tlaZ060 CR f1�6c1 <br /> A¢ auNr ¢onEsr forfeea and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING A D COMPLIANCE ACTOVOveLEDGaIENT: L the undersigned Applicant,certify that I am the Omnen Opemrrr,or ADA1Mnzrd AgOd of Ibis Business,and t acknowledge that all PERAUTFees, <br /> PENALrfEG,EA£oRcNnr,Yr CD wr.FS andlnr Holouv f HAAGAg Associated with this operation win be billed In me fit the address Identified above ns the drronyArADDRLTI for this Site. I also Certify that <br /> all information provided on this apphmnon Is trite and correct;and that nil regnlnled attiNlies will be performed In accordance.11h.111 Applicable SAN JOAQUIN CDuNTv Ordinance Codes Antler <br /> Standards and STATE and/or FEDERAL Lmvs and Regulations. As the undersigned owner,operator,or agent of the property located at the above fncibtyhiteaddress,I hereby Mithoriu the release of <br /> any and all nesnns and Stnim mental assessment information Is SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and al file some time it is <br /> provided[Date fir Any rcpresentmive. <br /> APPLICANT NAME(PLEASE PART) �0.1LL r�A%1IW(.t ff� SIGNATURE <br /> L TAR ID# <br /> TITLE �lA QtA -V`BE <br /> Ap roved B V� Det] Accoundn OIRca Proteesl Com ktatl s Ogle / �/ <br /> SITE MYDOATION AMOUNT PAID OATE�OF/PAYMENT PAINENTTYPE R EE�IPyJT# C�H�EyaCK# RECEIVED BV WOHH PPLn/Jb_PyVE, <br /> VV �.9 Sg <br />