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San ,,,--.auin County Environmental Health Dom,-rtment <br /> DATE MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> G Zl7I SITE MITIGATION&LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDN CASE# UNIT IV <br /> OWNER FILE'COMPLETE THEFOLLOIWNG PROPERTY OWNER INFORMA ON: CNECR7F OWNER CuRRENrcyoNFxEwnNEHD <br /> PROPERTY OWNER NAME .- 4- ) <br /> FirstM! La t PHONE NUMBER <br /> BUSINESS NAME &MAILADORES5 <br /> Owner Home Address <br /> 2-1 ( <br /> city STATE ZIP <br /> 1--Ob I b <br /> Owner Mailing Address <br /> z t - T R <br /> Mailing Address City State ZIP <br /> ov t c z go <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SITE MITIGATION ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEAIfUP_W QUALITY_HW PIPELINE INVEsTleATKIN_LOP— <br /> FActuTYID# INV# ACCOUNTID PR#1RO# ASSIGNED MPLOYEE LEAD AGENCY R <br /> EHD WQCB OTSC EPA <br /> I. <br /> FACILITY FILE COMPLETETHEFOLLOww BUSINESS I FACILITY/SIT INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEAL DEPARTMENT? YEs ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE Df regulated Business? YES ❑ No I <br /> BusINEss1FACILITY1SiTE NAME <br /> SITE ADDRESS SUITE# BUSINESSPHONE <br /> 3 1 S T c e,l <br /> CITY, STATE ZIP <br /> 7-0 CcTOA( C SzoS <br /> BOARD OF SuPERVIsoR DISTRICT - LOCATION CODE - ..KEYS - KEY2 ... <br /> Mailing Address IIDIFFERENTlvm FacffWAddress Attention:orCare Of(optfonal) <br /> Mailing Address City STATE ZIP <br /> SIC CODE. :APN#. _. _ - COMMENT: <br /> S 37007 _ <br /> THIRD PARTY BILLING INFO: Complete if Billing Party is different fmm Prorarty Owner or Facility Operator identifiedabove. <br /> BUSINESS NAME Attention:orCare Of(OpUonag <br /> C4 a Rs 1] .fe A 5 e <br /> Mailing Address PHONE <br /> L S c1 F A Zp D 7D0 <br /> cmSTATE G G �& zP196O<5 <br /> dc�tte for fees and charges OWNER CIUTYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKN LDGMENT: I,the undersigned Applicant,certify that I am the Owner,o perutor,or Authotizerl Agent of this Business,and I acknowledge that all PERMIT FEES, <br /> PENAL77ES,ENFORCEMENI'CHARGEY andler HOURLY CHARC;EY associated with this operation will be billed to to at the address identified above as the ACCOUNTADDREss for this site. I"certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be pert rmed 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 f the property located at the above facilitylsite address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH.DEPARTMENT ilable and at the same time it is <br /> provided to me or my representative. <br /> APPLICANT NAME(PLEASE PRINT) e' (J Y/ F R L,' TOE C SIGNATURE <br /> TITLE TAX ID# .2-9-5"'89 2 G C A <br /> STAFF &F DGO(5-( s7 _ 16- 12977 f-E)-EreA L- <br /> Approved By Date A...ntinji Offes Prxessing C pie"By Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY W�O]RN PLAN PE <br /> FEE:,t <br />