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From:STANTEC Is 9168610421 09/2j(12 10:50 #386 P.0021004 <br /> San Joaquin County Environmental Health Department <br /> DATE (�_a e a MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION& LOP <br /> AMARWAREAS FOR WD Vag cmLy OWNER IDs ;�a .� DAaEap�Co( UNIT N <br /> OWNER FILE:COMFLETE TNEFOLL=City <br /> (OW/NO PROPERTY OWNER/NFORMAnoom- CNLEcxn OWNER CUAWaVVjal'ONFREWTH END (` <br /> ER NAME Vr C-,des' S Sq ; C, \ 0_IFirst MI Last PHONE NUMBERE Address508> C NAS T 5�TcCITo t\N0 <br /> gedrew Sog I-}A2Ts Cky a State <br /> s��� �� Zip a saoc� <br /> CORPOMTION❑ INDIVIDUAL PARTNPRSAMP❑ FEDAOENCYIl OTHEp I] <br /> SITE MITIasiTiou_ENn kohnsh NTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPEYNE INVEST96ATON__LOP <br /> FAOILITY IDS IxvN AccouNT 3 �Op -3 q ��uuoru LEAOAcENOY:EHD,_,�,Ry/QCa�DTBC^EPA <br /> FACILITYFILE COMPLE7E7NEFOLLowlimBUSINESS/FACILITY ISITE lWaRManoli <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEE ❑ Noe' <br /> Is this an ExISTINo Business LOCATION but a NEW TYPE Of regulated Business? YES ❑ N00 <br /> BU61NuaVFA0urWSREN"e C I4u.V 1 zoo &`O. <br /> o <br /> BREAODRE88 N SUrtEa Business PHOxE <br /> JcC7$ CE4(�RTE� C��P 1 <br /> Cm4(oiz - 3L4 <br /> -5-1 ()(-c7b \ BATE ZIP <br /> YVN A9 5 2 0(0 <br /> BOARD OPSUPERVISOP DIBTRIOT I LOCATION CODE I Rett �,(Ei,2 <br /> Malang Atldress NDIFFERENrdmw FecYEdAddhoss Attention:or-Cam Of(opbhw# <br /> Masing Adtlreas City <br /> STATE ZIP <br /> SICCooE APNS _/JL((]-/4 COMMENT: <br /> THIRD PARTY BILLING INFDI Complete)if Billing Party is different from property Owner orFacillty Operator idenUredabove, <br /> e <br /> Moffinp AAddress Mu <br /> c <br /> ABeau.;archon Of(op&Ww) <br /> 301 - KI LC>p RG (LoAb fTE ipo PHONE <br /> 91r.� g(D(- pyoo <br /> c O Vuw _ �AE \ LP 1 SLQ TV <br /> A=oiL rAeDAEae forfeits and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> SRunG nND COAmLuacE AC%NOW LED : 1,Die undersitsed Applitan4 artily that I om the Owner,ON tr 1,or Aalh.,iWd Agent of this BmtaeM,Sad 1 gehxowkdpe that as FEgM/r FEES, <br /> JoENALT/ET.ENFORCEMENTCAARGES and/or HOURLYCHfeGa aeWtleted wile this OpteatlOB will be Wiled to ale at Iht edMas idendnea show as the ACC011ATAnnaMS for this ate. I also venlry/bat <br /> ell leformatiou provided ea thls applintioa is orae Sad torrent,gad that el rosubted aMvithas x911 N Prettrmed in seardaane with all apptinble SAN JOAOUm Cocm Otdinbuee Codes and/or <br /> &andards and STATE..d/Mr FEDE"L Laws Sad RedulatioaA As the undenipled owaer,opewtor,or arms Of the property bleed at the above fsdlidhite adduaa 1 hereby authorlu the rekoae of <br /> any and all result,and mvino nMntal aMeMment information to SAN JOAQPIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ae soon u it b l.u.ble and at the same time N h <br /> PAPPLIC site Nr My (PLEA EPRI Imo,' '(�J ./��} <br /> APPUOANr NAME(11PLEABE PRINT)/�� \t\yiA;1�C.nlc'_ SIOHATURE <br /> TITLE SIi N I O P l}';t.J_lJ lJ'L S� •J TAX ID C <br /> noose Deb AnaaMtl Olnm Prxaaanp Com Nbtl B p� <br /> BITE YITIO/AJTpN AMOUNT PATO DATE Of PAYMENT PAYMENTTYPE RWEPTI DHECxF Recerveo Br -WORD PJAN PE <br /> FEE:; (/ <br />