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San Joaquin County Environmental Health Department <br /> DATE C MASTER FILE RECORD INFORMATION 6'1MrR95l GREENFORM <br /> SITE MITIGATION& LOP <br /> SHADED AREAS FOR EHD USE ONLY OWNER IDM ooCASE ft UNIT IV <br /> OWNER FILE:CONPLETE THEFOLLOWING PROPERTYOWNER hvFoRmAT1oN.- C"FcmIF OWNER CURRENTLY ON FILE WIril EHO <br /> PROPERTyOwNERNAme <br /> First M, Lost PHONE NUMBER <br /> .............. <br /> BUSINESS NAME E-MAILAoDREas <br /> czt,Pik=11 <br /> Owner Home Address <br /> City Ula. 7 2012 AXATI <br /> Owner Mailing Address. y-- <br /> W�Ai Hi=AiTH <br /> Mailing Address City r!WRGNMFS-F <br /> PERMIPS 0410ES state Zip <br /> CORPORATION❑ INDIVIDUALE] PARTNrnsior,El FED AGENCY❑ OTHER❑ <br /> . —2— <br /> SITE MITIGATION ENVORONM12NYAL ASSIMSMENT VOLUNTARY CLrANUP// WATER QUALITY HW PIFEUNM 11MVESTIcATION—LOP <br /> INV# <br /> FACILITY ID A000uNTIO 4r;D EMPLOYEE AD AGENOY:EHD—RWQC B DTSC EPA <br /> 1��Uffi &6`5131 �5C CJ KfA)j - - <br /> FACILITYFILE COMPLErE THEFOLLowING BUSINESS/FACILITY/SITE INFoRwTlow <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> VA <br /> SlTaADDRESSn SUITE# BUSINESS P140HE <br /> CITY STATE zip <br /> Fs ARD or SUPERVISOR DISTRICT I LOCATIONLOCATIONCODE KEYS Kn <br /> Mailing Address IfDIFFEREN rfrom Facility Address Attention:orCare Of(opiYonal) <br /> Mailing Address City STATE zip <br /> _7 I <br /> COMMENT: <br /> THIRD PARTY BILLING INFO' Complete if Billina Party is different from Property Owner orFacility Operator identillplabove. <br /> BUSINESS NAME Attention:orCare Of(optional) <br /> Mailing Address PHONE <br /> CITY STATE zip <br /> A00V11tKrAj2DBM for fees and charges OWNER FACILITYIBUSINESS THIRD PARTY BILLING <br /> BILLING AND CO)IPI..IANcEAcl(NOwLF.I)CNIENwl': 1,the uncles sign ed Applican I,cerl 1 y I hat I anithe Oivner,Operator',or,.4 olhorized Igeril of this Business,and I acknowledge that all PERva Ft--'Fs, <br /> llex..itrm,s,FvFoRo.',w.,,vr CHiRk;rs a nd/or HouAL I,CY-;RGri5associated%vi tilt his Operation will be billed to tire at the add rcss!(tell titled AbOVC IS the ACCOUNTA DDRETS for this site. I also certify that <br /> all information provided on this application Is true and correct;and that all regolatedactiAties will be performed Ili accordance will all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDEIL%L Laws and Itegniritions, As the undersigned owner,operator,or agent of The property located at the above facility/site address,I hereby authorize the release of <br /> any and all results and enviroi I I I ses it. lbrimition to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ."or, as soon It pliable and it tire same time it is <br /> APPLICANT NAME(PLEASE INT 'in <br /> Ill" <br /> provided to tire or ni�,represellial:ve.a <br /> s PR <br /> SIGNATURE�uu <br /> TITLE TAX ID <br /> r <br /> Approved By Data Accounting Office Processing Completed By Oate <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENTTYPEREC:FIPT# HECKM WORKPLAN PE <br /> FEE: <br />