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SAN JOIN COUNTY ENVIRONMENTAL HEALTH DEPOMENT <br /> DATE MASTER FILE RECORD INFORMATION "MFR" GREEN FORM <br /> 3 s I SITE MITIGATION& LOP <br /> S END UBE ONI v OWN[AIW g bo0gsl�. CAaE ... SaDvc4ISO UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY INFORMATION: EH <br /> EHO <br /> PRDPERIv OWNER NAPE l / <br /> Fmr M) LST PNONENUWEA <br /> BUSINESS NAME E KADORESS <br /> �hGk ?o LTR LLL c4 f fi Alk <br /> O"ER HOME ADDRESS <br /> 2o2oSEhST v,<NuE <br /> GITT F R en Aro �'Cf�- zw R3 7 <br /> OWNER MANNM AWRIMS ? D <br /> MAKRNSADDaESSCrry fRfSNo <br /> ❑GINtPduTfoN ❑INIMR09N. ❑PIJIINERNlp ❑GOVERRMOO AW/IC• ❑RE*I IBIE PARD' ❑OTNEA <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_VIAT9 Yi16fTYX HIN PIPELINE INVESTIGATION_LOP_ <br /> fACIIIT'I�S �'INVN '[ACcoUNr 111 i=` n pRMf�ON ': <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ERVIRONMENfM mk%TN Ow-owIENT? YEs No ❑ <br /> IS THIS AN EIRSTING PROJECT LOCATION <br /> , <br /> BUT A NEW SCOPE OF WORN?I YES ❑ no <br /> BUSnREBSIFAdLRY/SffElPRO1ELT NAME Z�L• Il. A/ ou(,�r p .// —(�& <br /> 00 <br /> SITE ADDRESS f PRQIFCT LO TION fill NT• rRIvC — " SDIIEF BDSSIESapt <br /> CRY 7� <br /> 6-toa n onj `u PC _._ 9SZdG-(IL <br /> �BawDF6MpEwuIFDR OMTRW'{+ �: LorwTnrICDDE �,_s itEYi hd .�,�I ,I { t✓ sk>a F3 �J , <br /> MAKxxIADDRESi,s OFFFADIT IRid1 FACpfiYADDREen •`rENTIOM:DNCkREOF(O^IAAWLJ <br /> MAILYIOADDREINIM --- STATE[ ZIP <br /> 5 ��' M1 C 'r ", bYl4'F S'Ir'r I a• •� 4 Y <br /> SIC -.)vnN .f y ".•�� F r - C _ rp-r L+ <br /> .11..Rcf'�.v_.i�K �,_ rj rd� ! n ���db � t. - w,{.,,. aX.•._ s 5Fv� <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM Peora Y Owwjt OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BWINESSNAME ♦11TENTION:ORGANS OF(IT^OOMV.J <br /> MAIUND ADDRESS PHONE <br /> CIT, STATE ZIP <br /> ACCOUNT ADDRESS To SEND FEES AND CHARGES: OWNER[] FACRJTYIBWSASB❑ THIRD PARTY BIWNG❑ <br /> BD t TRC ANT COARLIANCE ACIDRQWI TDGNENf: 1,the oadenl9wd Appeam,rrrflly thal I nol We onmer,Opem*r,AvdmrWAg x4 or ReVowibfe Parry and 1 ark..Wkdge lb.1 all PEAhnTrm,, <br /> P£NA[TIFS',ENFOAIT.II£Nr EY)AACET and/or HOLALT f}rARGEe associated wilb WRs project wiS be bB1ed to nN a1 Re address IdeMlDed ahqe n the ACCODxrADDREss IM 166 si4-1 giro afUfy thvl all <br /> hsfomsedoa provhtrd on WRs appliratloo Is true and correct;and Rat AB regma/ed acDvlU n'lll be performed to mcontaae,pith aD appgrable SM JOAQULT COMWr Oalo , CE CODES aadlor <br /> STAAVARDsaud STATEvndb.-Fm ATLAWaaod RFD DONS. Ar the mdelvlgned Owner,operalor,Aulhor{�d Agml,ar Aepowdbk Parry for lbeprojM lorAled above nodcr facBirylslle addms,] <br /> hereby auRorize Ibe nlease m aoy aad aR resWU,npM'U,avd tuber wNromaeeNl usetrmrel WnrmaDoo Io Su:]OA Wd CbrNTY ETTNfP1T6ATALHEALTD DEPARTAtMT az soon M N U rvaWbk <br /> aadm the..time It b provided lS Six or my repmcmativeA..y <br /> APPLICAN�TNA�MEyI sP1LE1ASEEP�R/IM) ^- �I y—,I ' Y�x�)/ RIONr,TUIiF ��pFe/��G('/FF�' <br /> T�zwl j / /r F N✓1LPA�lN. G�•aJG�a-fI"d^i ��5 TM IDS 4(it <br /> Ae.ROVEO BY DATE ACcwlrrtwa UilICC PROOEeMNC COMPIErtn BY MTF p <br /> SRE MrttDA AIgU�XyTP 10 DaMC;FPAVNENT PAYMENTTYPE IRECEKTI (.YIECKN YRECENED BY I)1IpbRAliq�crllwi-E <br /> FEEIf,'' / 3.PL�' _?pmea 4�Itl� �oGlu �... <br />