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San Joaquin County Environmental Health Department artment <br /> DATE l 1 _ t L <br /> MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADEDAREASFOREHDIBILgHLY OWNER ID# CASE# UNIT IV <br /> OWNER FILE:COMPLETE 7N99EFOLLOW/NGPROPERTY OWNER/NFORMA T/ON: CHEarw OWNER CuaRENTLroumEnom EHDQ <br /> PROPERTYOWNERNAME <br /> First MI Last PHONENUMeER <br /> BUSINEw NWEPC-A $E EHMILADDRESS <br /> Owner Home Addraef <br /> City STATE LP <br /> Owner Mailing Address, <br /> Mailing Addresa CRy Stet CA ZIP 94101, <br /> �/ SAN F(2AN CISCO <br /> CORPORATION Ed INDIVIDUAL[] PARTNERSHIP El FEOADENCY❑ OTHER <br /> SITE MITIGATION_ENVIRONMENTAL AssEnI ENT VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILIWID# INV# ACCOUNT ID PR#IRO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD RWQC DTSC EPA1 99-7 _ <br /> FACILITY FILE COMPLETE THEFOLLOW/NG BUSINESS/FACILITY/SITE/NFORMATION. <br /> IS this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> IS this an EXISTING Business LOCATION bUt a NEW TYPE of regulated Business? YES ❑ No Ly <br /> BUMNEssl ACI SrrE NAME �C�p <br /> SITEADDRESS ��J SaAtN G£N SURE# BUSINESS PHONE <br /> S StuT (wa X32 Esso <br /> CITY o c v BCA zipr'IS203 <br /> ST r-1 T rJ <br /> BOARD OF SUPERVISOR DISTRICT LOCATIONCODE Ke l KEY2 <br /> Mailing Address MDIFFERENTfr Fe il/tyAddmm Attention:orCare Of(optlau/J <br /> Mailing Address City SANS <br /> zip '1 <br /> SASANSFPLANC1r.000 ( ^ Cl4)Dr, <br /> SICCODE APN# COMMENT: <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFacility Operator identified above. <br /> Attention:orCare Of(optio W) �oM"SL CAU. jo,C <br /> Mailing Address BUSINESS NAME �QCA�IC �� INC, C <br /> PHONE /c)25 2� <br /> ZCIq p J 1 VAk I�UAD .51..11 30C) l ) L�- ))Ov <br /> Cm WAUQLAT CVLZEa✓l� STATE ^ LP 94s9-- <br /> ACCOLA¢ 8y for fees and charges OWNER FACILITY/BUSINESS ��H THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOw LI'AX.MEN 1: I,the undersigned Applicaal certify that 1 am the OrNer,Operator,or Authorized Agent of this Business,and 1 acknowledge that all PEMin'FEE¢, <br /> PFha/.T'/Eti,EA'FoRt'£.stENTCRARGE.c and/or!iota/yCiiO GESassociated with this operation will be billed to me at the address identified abave as the ALCouA ADDRESS for this site. I also certify that <br /> all information provided on this application is Rue and correct and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at t bore facility/site address,l hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP TA ENT as n as U i on, <br /> and at the same time it is <br /> provided to me or my representative. GA/ .. � SIGNATURE _ <br /> APPLICANT NAME(PLEASE PRINT) P-OVA"EL_ iJt <br /> TAX ID# <br /> TITLE ' <br /> Approved By Date Amosurting OIRoe Prxmodu Complete ByDete <br /> SITE MIT& AMOUNTPAID DATEOPPAYMENT PAYMEw TYPE RECEIPT# CHECK# RECEIVED BY WORN PLAN PE <br /> FEE: <br />