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San Joaquin County Environmental Health Department <br /> 1 DATE MASTER FILE RECORD INFORMATION i"MFR'r GREEN FORM <br /> SITE MITIIGATION&LOP <br /> ' EHADEnAREAsFOR RHO WEONLY OWNER ID# CASES UNIT I® <br /> i OWNER FILE.COMPLETE TNEFOLLOW/NG PROPERTY OWNER INFORMA TION: CxEcxIa OWNER CarvnEnrzrorvnce w�rn7 END E] <br /> j PROPERTYOWNERNAME Fe fnq 0 Qf46- 9 6 J <br /> fFTt MI Ld51 PNONE NUMBER <br /> I BUSINESSNAME EMAILAODREas <br /> Olt- <br /> 1 Owner Home Address <br /> t t <br /> ctty C4 STATE ZIP <br /> � Owner Mailing Address <br /> Mailing Address Gty + Bfa ZIP <br /> COSPOMTION''��❑// INDIViDUAL14 PARTNERSHIP❑ FEOAOENCY❑ [ ) CITHME] <br /> AITB MITIGATION L�.ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE ImmaNGOATION_LOP <br /> FACILITY Ib# INV# ACCOUNTID PR#/RO$ ASSIGNED MP , EE LEAD AGENCY!EHD RWQCB_DT$C_EPA_ <br /> -733 53 <br /> FACILITY FILE COMPLETETNEFOLLOWING BUSINESS/FACILITY/SITE lwom AT/ON' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES❑ No <br /> y <br /> Is[his an ERIsTINe Business LOCATION but a NEWTYPE of rgulated Business? YES <br /> BUSINESSIFADII-miBiTENAME I <br /> ri\A ce- <br /> SREAODRE69 _` `� �- sone# Buffl(31 F8PHONE <br /> i CITY d1-!V'1 . 1 STAT 7JP Ed�-�5�/y6 <br /> I BOARDOFSUPERNSORDISTmCT LOCATION COOS Hcrd HEY2 <br /> Mailing Address MD/FFEREAH`fta nFa➢11&AddrtTsa Attention:Pr Care Of(dpf/➢na/f <br /> Malting Address City STATE ZIP <br /> SICCODE APN#/!' �J//O O� COMMENT: <br /> THIR®PARTY BILLING 1Cample a If Billing Party Is diffesentfrom Property Owner orFacility Operator identified above. <br /> Foe <br /> BUSINEsal' y e <br /> Attention:*room Of(➢pfkz*of <br /> y o L (\Vi� nMP-44j <br /> Mailing Address Pxone DVV S71 3W <br /> CITY STATE 21P <br /> t <br /> AW-O/AVAPPaBES3 for fees and charges OWNER FACiLiTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOwLEUGNIENT: I,Ile undersigned Applicang certify than l nm the Owner,Operener,ur Anthori[edAgeld of this Business,and l acknorvledge llmt:dl PERdI?FEES, <br /> PY ALTIES,RVPaRGGtP.'WCH,igcES andfor MOURLY CmARG£Sassoelated-'illi Illi!npCMdnn bill he billed[n 111C nr IIIC 9ddrC59111enNgfd:lDn\C IIr Il1e R(Cn(/VT/1➢UHECS for this site. 1 nint Cerdfy flea <br /> all Infornmllon Provided on this nppileadon Is RILL`aad enrrecH and 11191 nil regnloled TfllVitles Will he pCrbrined In auordatwo with all nppilenllle SAN JOAGUIN CGIINTY Ordlonnee Codes onto!' <br /> Standards and STATE mldlor FEDEaU Lines and Regulations.m the undersigned mener,ole.10r,or-gent of the properly located at ',o of <br /> any and all i'esela and cmironmcnlal assessment inflammation to SAN JOAQUIN COUNTY ENWRONMENTAL HEALTH" it is <br /> provided to nm army representadyc <br /> APPLICANT NAME(PLEASE PRINT) �f�GPirY_L(rIS _Tr SIGNATURE j_ r,,.—•/(/�. L.a�J.� <br /> TITLE ( TAX ID# <br /> Apprered8 Onto Ac...num <br /> ns O -a Pra... lCom late-- OaIA <br /> SITE MITIGATION AMOUNT PAID DATEOP PAYNENTPAYMENYTYPD REDEIIK$ CHECKS RECEIVED BY WORKPLANPE <br /> FEE: <br />