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San Joaquin County Environmental Health Department <br /> -TATE MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> CASE# <br /> SHAD E-- � OWNERID# UNIT IV <br /> OWNER FILE : COMPLETE THEFOLLOW/NG PROPERTY OWNER /NFORMA TION: "'HEI OWNER cuxaexrzYONFIewrra EHDEj <br /> PROPER OWNERNAW hQ in shIL 0 -7 <br /> First MI Last PHONENUMBER <br /> BUSINESS; NAME // <br /> ( /7 (TSS r)/ A& Ei,/AILADDREss <br /> Owner Home Address v l• l� <br /> y � GLi.Q. r� f—rvo r Li/ <br /> cry T� <br /> STATE ,z,P r <br /> Owner Mailing Address G rr J Z <br /> Mailing Address City <br /> 71111 Bram G � zip <br /> �y � <br /> CORPORATION ❑ INDIVIDUAL 19 PARTNERBHIP ❑ <br /> FEDAGENGY ❑ OTHER [] <br /> SITE MITIGATION _ ENVIRONMENTAL AsgBBgMCNT _ VOLUNTARY CLCANUP _ WATER QUALITY_ HW PI PEUNe INVISTI CATION LOP <br /> FACILITYID# IHV# AGCoUNTID PR#i R0 # <br /> AsSION OEFIPLOYEE "LFA AGENCY EFID gyygC`8 DTSb_EPA _ <br /> FACILITY FILE COMPLETE THEFOLLOWING BUSINESS / FACILITY / SITE /NFORMA T/ONI <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes <br /> IS this an ExISTINO Business LOCATION but a NEW TYPE of regulated Business? El No Q' <br /> YEs ❑ No <br /> BUSINE93/FACRJTV(SITENAME <br /> S CTG b <br /> BII'EAODRE39 <br /> Tq F/ SUITE4 BU91NE9SPH NE <br /> CITY y/J r C/" zo; <br /> S�DU��- ZI STATE LP <br /> BOARD OFSUPERVIDOR DIBDIICT LOCATIONCODE I(EVI <br /> Kee <br /> Mailing Address YfD/FFERENrfrom Fac///fyAn4aI <br /> Attention: orcare Of inetk ng <br /> Mailing Address City <br /> STATE ZIP <br /> SICCODE APN # CDMMF , <br /> THIRD PARTY BILLING INFO: COMpleteif Billing Party is different from Property Owner <br /> BUSINESS NAME or Facility OperatoridenUfiedabove. <br /> q <br /> Attention: orcare of 1pnp Lo! '-�t �9 / _ <br /> Mailing Address /L C � .� �hG <br /> t114?t114? 7 �• / T/ �—S PHONE �/ <br /> on /f '7�� - <br /> STATE LP <br /> AnroS,vrAapgE s forfees and Charges OWNER FACILITWBUSI ESS <br /> THIRD PARTY BILLING <br /> BILLING AND CONTPLIANCE ACKNOWLEDGMENT— <br /> : I, the undersigned gppDcant, certify that I am the 0oner, Operator, ar ArrrAorired Agent of /his Business, and r ache <br /> T'EN LTTPS,Erv£oRCeAr£m' C aAees and/or HoeRCYCH GEsassociated with this operation will bebilled So meal the address identified above as theAcmurvrAonsEssforltbis that alloarrTF£S, <br /> all information provided on this application IS true and correct and that all regulated activities wB1 be performed in accordance Dith all applteffile S Y JOAQUW COMTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations As the undersigned myner, operator, or agent of the property located At file above fads tyAlte address, I hereby authorize the release of <br /> any and all results and Environmental assessment information to SAN JOAQUIN COUNTY as soon as it is available a <br /> ENVIRONMENTAL HEALTH DEPA NT and it the same done it is <br /> provided to me or my representative. <br /> APPLICANT NAME (PLEAsEPRINT) <br /> SIGNATURE <br /> TITLE ACI )PGS f C IfI L Xyz� TAX ID # <br /> � 8o3oy6 �- 6 <br /> Approved By Oto gcccungng office PrpceeainO Cempleled BY <br /> SITE MITIGATION AMPE OUNTPAID DATEOFPAYMENT PAYMENTTYRECEIPT# DAN <br /> FEE CHECK# RECEIVED BY W RK PLANPE <br />