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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> DATEg 1 i 3 MASTER FILE RECORD INFORMATION"MFR" OREEN FORM <br /> t SITE MITIGATION& LOP <br /> *M=aA"A"V&MIDMM-OW OwNEA IDi CAEEi UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPONSIBLE PARTY INFORMATION: CNEexIFOwRenMCURRexrzroxnLewJTrt�{N EHD � <br /> PRMairry OYRIeR � Z <br /> NAME ea — u - 8'l <br /> FIRST MI LAST PHONe NUAISER <br /> 1 O o 16 EMAIL AODREN <br /> BUMNeiiNAYe , <br /> , I <br /> A Ulel✓� vA�O` 11 <br /> ORNERHOMEADDRESS <br /> Cm STATE LP <br /> OW MMUMADDREM <br /> WRJ�MADDREMCM SSD 1Uto <br /> STwre Lv n��O I <br /> OD COMPONIITR)N ❑INDIVIDUAL ❑PARTNERSHIP ❑GDYERNMENT AGENCY ❑RESPON&ElE PARTY —1 ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FAOIIdry IDi INvi ACOOUNT ID PRNROi ASi1GNEDEMPLOTEE LUOAGEApOr.EHD2 RWQCB`DTSC_EPA_ <br /> t OHNN <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No K <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? /f YES No ❑ <br /> BLgINESNPA0141Y181TFJP110.IECT NAME AA��C ,tart} OQ. oxpl d <br /> GMADGRESSIPROJCOTLOCATaN � ' 1 , �J�/�' p� ( 1_ n ,�4�T�TEi __I <br /> Cm OI—IL- (,l./ l�l<1 Are LP O bo <br /> in <br /> BOARD OP SUIRMYOWR OMTNOT (, I LOCATION CGDe O KeY7 KEY2 I V <br /> MMUNOADDREtM,PdFPERENf PROM FAGLOY ADORE99 ATTENTION:ORCAREOFfb0` WALE <br /> Sa 64- <br /> M `,Y !J STATE LP <br /> MUNO ADDReSBCm O <br /> SIOCOM / APN0 !� 3� COIrENr. <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> Blend SNAME ATTENTION:WCARE OF(OFTIOAMLf <br /> PHONE <br /> MMUMADOMIEM <br /> STATE LP <br /> Cm <br /> ACCOUNT ADDRFbE TO SEND FEES AND CHARGES: OWNERE] FACILITYIBUSINESSLJ THIRD PARTY BILLING❑ <br /> HILIT.G AND C E A HOW LEDgMENT: 1.the muknigned Applicnnl,cerlify that I nm the Ciwo,,Operator,ARlhnr1,1d A,,U n/Rerptm.vible Pnrty and 1 acknowinlge that all PER.NIT FEES', <br /> PENALTIES,ENFORCEMENTC/GRf.EPaMVOr HOUR,I'CHARGF..1'xaoclaled with Ihk project will be billed to me at the addela,identified above a1 the A CCUUNT A UORE].1'for this site. I ekU Certify that all <br /> Information provided on this application is true and correct',and that all regulated acfivifiel will be performed in accordance with all applicable SAN JOAQUIN COUNTY ORDL NCE CODES and/or <br /> STANDARDS aml STATE andlor FEDERAL Laws and REGULATIONS. As the undersigned IMoer,Operator,Authnri.ed ARen4 ar ReeponslNe Party for the p 1lormad above and HUyhile whir.,I <br /> hereby authorize the release of any and ell remit,reporls,and Other environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENT EALTIt DEPARTMENT s s as It is available <br /> end al the same time(ties provided to;me or my repFlse�te ` 1 43r s <br /> APPLICANT NAME PLEAS[ MM PLL/(//I/ fa�w SaruTDne <br /> TITLE TAE IDi <br /> Apyppy[p RY DATE ACCpMTINO OFFICE PRO "Ma COMPIETIED BY Dwre <br /> irMMM"T" AMGUNTPAID DATEMPAYINENT PAmen YPE R[: is111 CHeDNi ReaoveD BY WORJt PIAN PE <br /> PEE$ <br />