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San Juin County Environmental Health Oartment <br /> DATE -5-r 2 MASTER FILE RECORD INFORMATION"MFR" GREEN FORM <br /> SITE MITIGATION & LOP <br /> SHADMAREaSF EHDUSE O OWNER IDR CASE# UNIT IV <br /> ( <br /> OWNER FILE: LEVETREFFOLL PROPERTY OWN ER SROW�N�ERL9MnoEWrvvdarB.EWrvWEHD � <br /> PactfeaTf OWNER NAME aF .` S &9) -6 <br /> First MI Last PHONE NUMaFR <br /> E LADoREEs <br /> BUSINEE I NAME <br /> ,T+ (3 <br /> Owner Hone Address <br /> CRY Loa, <br /> CWt q s-L <br /> Owner Moiling Address <br /> MNINg Address CRY Stet <br /> CORPORATION❑ INDIVIDUAL❑ y PARTNERSHIP❑ ❑ <br /> FED AGENCYOMER� <br /> SITE MITIGATION_CNRONMQfrAL AtfWMMNTjy VOLUNTARY CLEANUP_WATER GUALnY_HW PIPELNE INvewr16ATiON_LOP <br /> FACILITYID# INV# ACCOUNTID PRR/RO# ASSIGNED EMPLOYEE LEAD AGENCY:EHD_—RWOCe_DISC_EPA_ <br /> FACILITY FILE C1oWLErETHERXLaxmBUSINESS/FACILITY/SITE <br /> Is this a NEW Business LOCATION riot previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES No ❑ <br /> Is this an EXISTING Business LOCATION bUt a NEW TYPE Of fegWated Business? YES ❑ No <br /> BUMNWSIFAGLRYfllT NAME? e <br /> WmAD� O SURE* BUSINESSPHONE <br /> C <br /> L.m, STATE LP <br /> 7- a <br /> BOAROOFSUPERWBOROISIRW N LOCATION CODE / KEr1 KEY2 <br /> M@Uing Address' ewsFkoWgcifP I- Af ration:wCae Of ftfiloraq <br /> Melling Address CRy STATE ZIP <br /> SIC CODE APNR ^D,, Cowllalr: <br /> TNIRD PARTY BILLING INFO: Complete if Billing Party is differentfrom Property Owner or Facility Operator identified above. <br /> BUSINESSNAME AUeMIon:wCae Of <br /> rapWarmV <br /> MaXhg Address PN)ME <br /> Cm STATE Zip <br /> ACCMMW-- for fees and ChargesOWNER FACILITY/BUSINE55 THIRD PARTY BILLING <br /> BILLING AND COMPLIANCk ACKNOW LEDGMENT: 1,the undersigned Applicant,cerfifv that I am the Owner,Operator,or Authorized Agent of this Business,and 1 eclmawledge that all P£RMITFEES, <br /> PENALHF,ENFORC£MENTCHARGET and/or HOURLYCHARGES associated with this operation will be billed to me at the address identified above as the ACC'OUNTADHRESS for this site. 1 also certifythat <br /> all information provided on this apidbation is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN CODNIY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations. As the undersigned owner,operator,or agent of the property located at the above fedhty/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART aooe as It is avail 1 d at the same time it le <br /> provided to me or my representative. / '°""'y '%*/�I <br /> APPLICANT NAME(PLEASE PRINT) ✓�C� ?`j r�P SIGNATURE <br /> TITLE _ TAx ID# <br /> �ra,re Po J -%J CfG .)=,-19 fa <br /> Approved By Ogle Acuauneng OIRoa Prooeealog Completed BY Date <br /> SITE MITIGATION AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE I RECEIPT# CHECK# RECEIVED BY WORK PUN <br /> /PPE <br /> FEE: a., I )v...... <br />