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Joaquin County Environmental Health Department <br /> DATE =San <br /> MASTER FILE RECORD INFORMATION"MFR is GREEN FORM <br /> SITE MITIGATION&LOP <br /> 1, 9NAo A EN. p NM P OWNER ID# CpSEN 5 J 13 UNIT IV <br /> OWNER FILE:COMPLETE TNEFOLLOW/NG PROPERTY OWNER/NFORMA TION,, DWWA`OWNER Cvaa£rrnroxsAEwmf EHD <br /> r <br /> 1 Fine Mf Lost Cd PHONE NUM9E (,,J <br /> BUSIHE9SNAME <br /> EMAILAOOnE99 <br /> LA ower�r <br /> Owner Home Address <br /> city STATE ZIP T <br /> Cq <br /> nA <br /> Omer Moiling Atle res. <br /> , Cent S� <br /> Maine Address CllJ/ + $ta Zip ^ <br /> DORPDMTkIN❑ INDIVmUAL� •VArWr PMmeadi IP❑ FEOAOERCY❑ !M J F❑ <br /> SITBMIMGATION ENVIRONMENTALASSESSMGNT_VOWNTARYCL UP_WATIROUALnY_HWPIPEUNEIN STIeAT10N_LOP <br /> FACILHYID# INV# 3��TID PR ao# Ass1aNED MPyoYEE LEAD AaENoY:EHD RWOCB_OTSC_EPA_ <br /> 53 �/ <br /> FACILITYFILE COMPLETETNEFOLLOWNGBUSINESS IFACILITY I SITE&FORMATION^ <br /> Is this a NEW Business LOCATION not previouely regWated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES [I No <br /> :SIMS:.EXISTINGBU9iness LOcAnONbuta NEw TYPEof ulated Business? YES ❑. No-Rf <br /> B SI1,Ha 8IFACRnYISNENAME �- <br /> ma,-, <br /> SnEAaeRESS SURE# <br /> Q-61 ' n S BUINr-P6 <br /> 3x' <br /> Gary BTAT ZIP <br /> 1 BOARDOFSUPERVISCHRONTRICT LocAric, DD9E XtYt XEYZ <br /> Mailing Address RDIFFERENTfewn Fac/lli Addreaa Altenllon:orCere Of(op1/ona// <br /> Mailing Address City <br /> STATE ZIP <br /> 1 <br /> 1 SIC CODE APN#/ COMMENT: <br /> Y <br /> j THIRD PARTY BILLING 1 Fot Cample a if Billing Party Is differentfrom Property Owner or Facility Operator ident#,erdabove. <br /> 1 BUSINE98 NgME p� <br /> i� VG✓1 L..I'1 V 1/' n ,Q Anandan:arcara or tapRonay <br /> i Mailing Address <br /> PHONE <br /> �vv szi- 3� <br /> Cltt STATE ZrA IP /\�^L/s— <br /> 9t�'pVdtTA�E,84 Por fees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> RILLINa ANDCOaRUANCe ArsN01VLe9GanRfT: 1,the undersigned Apppcant,certify that l am the Oliver,Operate,,orAmGerized Agrsaof this Redness,and l acknos.'Iedge that all FERV FL'ey, <br /> I4'NALn£S,ENPORCFJIPM CNAAGES em#or Mount,CHARGES a55ofl.t d\Villi this nperaNnn\VRI be billed to Hit at file addece,ldentlged above as fla ACriwwrAOfINESS fertile site. 1 alta Cerllfy dist <br /> all information pelvided on this application is trne and tarred,,and that all rephiled aellviall will be perfamird in amol'dnnee With all opplienbie SAN JOAQUIN Crour v Ordlnaoee Lades and/or' <br /> Smndeals and STATE Andlor TEDERit.Laws and Regillmilnls.A.i Ike undersigned money npemtoq or egenl ordH property located al n <br /> any and aN results and aniromnelml aMmsmenl inlhrmatioll to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH r it Is <br /> provided to me army reprewntative. r <br /> APPLICANT NAME(PLEASE PRINT) CQT rtLR'Ar,,CIS Zf- SIGNATURE'-_-- <br /> TITLE TAX ID# <br /> pruved III B Dole pccsVnane OMea Praceeelnp Complabd By Deb <br /> SITE MIneAnoN AMOUNT PAID DATEOF PAYMENT PAYMENTTYPE RECEIPT# CHECH# RECEIVED eY WORK PLAN PE <br /> FEE: <br />