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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> a n GREENFORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION &LOP <br /> .4 CASE UNIT IV <br /> HF�_ONLY <br /> OWN"100 <br /> CNECM/f ON'IVERMCDRRENRYON ANENYTN EH <br /> El <br /> OWNER FILE:COMPLETE PROPERTYOWNERIRESPONSIBLE PAWN INFORMATION: <br /> PROPERTY OWNG NAME PHONENUMSEn <br /> MI Ln9r <br /> F/F5i (� I @WILApDRESS <br /> BUSINESS NAME Da,I aow-t-'CM 2al� O O l6N <br /> Owxcn Have ADoaEee <br /> STATH LP <br /> CITY �F�+� / <br /> OWNERMMUNGAUORESS 1 D C) '1J UK9rATe�b Q <br /> Tr 150 I <br /> MAWMADDREFECm C'JI O� 101) If/j LP <br /> T _L [I OTHER <br /> �.y ❑INDMOUAL ❑PARTNERSMP ❑GOVERNMENT AGENCY C1 RESPONSIBLE PARTY <br /> DO CORPORATpN <br /> VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION__LOP <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_ EPA__ <br /> FAdIJTY ID/ IxvA ACCOUNT ID P OA ASSIONEDEM UMI, LEAD AGENCY:EHD II RWQCB_DTSO_ <br /> ti3�it2.r. 22 St i �v.. <br /> FACILITY FILE:COMPLETE BUSINESSISITEIPROJECT INFORMATION: YES No <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES No D <br /> IS THIS AN TOASTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? \ <br /> 611etMESSrFA01lfTYrBm/PaOAEOTNAME ,tea „Ava� OILIi d>J <br /> �I AB BUSix PN011! <br /> SDEADOIEESSIPROJECTLOCATMN 2�,/ (" 1 1• f/l.A ,� A I/�I`1ngT �OQ yam. <br /> •f'J l�� l.V• VVI ATE P gbol <br /> Cm . 11'' <br /> UL C <br /> BOaI10OP BUrmYMORDNrntoT D I LOCATION CODE 6 <br /> KlY1 KeY! <br /> ATTENNON:ORCAAEOF(WEnN`I0 <br /> 1MIUMOADDRE68,1(d(FERENi FSOMFACILIIY ADDRF$E SR / <br /> STATE LP <br /> MATUNo ADDRESS CITY FA n L J <br /> 810 Coot APN i (k ^I <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY NAneImDRTIE ORCAaE OF(wypNAuSPUMOUBLE PARTY ENTIFIED ABOVE. <br /> BUSINESS NAME <br /> PHON! <br /> MMUNG ADDRESS <br /> STATE LP <br /> Cm <br /> ACCOUNT ADORtlS TO SEND FEES AND CHARGES: <br /> OWNERS FACILITYIBUSINESSD THIRD PARTY BILLING0 <br /> B N C L ACK OwLEDGMENT: L tM1e undm(gneJ Applicant,arHfY that I am Mt(Hoer,OPeru/nr,AurAnrrL¢d AI,MnA rrr ResprmsiArc Parry end 1 acknows dge Undo.ail PERanT.t.11 <br /> bole-1 the ACCO <br /> PlaYILTIM,EHT(ML'EHEMr CHARfiE3 and/or OrIUHLP L'HAR(iET sand that allthh this PJJacHv fitr wect will be ill lbe P rformedein attOfdente wid9scidness av118PPIitvb e S N JYAQVIIN COUNTYDO 1RDL I ry¢CQnFs tand/ot <br /> inrormadon provided an this application is Irv.and corrad;a rare AlohaAwh.led'Agec "I sSetpnnth.l Para Por the p floc aad.basc and IIby/,iteaddrm.I <br /> STANDARDS aad STATE and/or FEDERAL Laws and REGRo. a S.o A91he imnanogn.d(Avaeq(JP. <br /> hereby euthorim the release or any end ell rnultl,rcporif.end other environmenlel et9e3`menf information In SAN JDAQWN COUNTY ENVIRONMENT <br /> 6ALYI1 DEPARTMENT t S A it u ewde <br /> and el the 9.me ba.it is provided roma or my repfjst��HG.-r /♦fI� s <br /> L rAWL/ 11T'sJN 910WNRE <br /> AlUCANT NAME(PLEASE PRINT) <br /> TMIDS <br /> TITLE <br /> DATE A') <br /> APPaDYN�• aATE ADCOUNONOORIce PaODE991Na CDMFLETEG BY WORE PWr PE <br /> RECEIPTS CMECNS RlOCIYED ly <br /> BGE IAmDAnoN AMWNT PMD DAieM PA llLl' PAYMlNTTYFE <br />