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SAN*UIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> « 99 GREENFORM <br /> DATE /oro r2 MASTER FILE RECORD INFORMATION MFR <br /> SITE MITIGATION & LOP <br /> OWNER ID# �[ X11 GI//f/'0 07 UNIT IV <br /> S EHDU EO V /\\� �I 1�� CASE# - „JI\VV � 8 <br /> OWNER FILE:COMPLETE PROPERTY OWNER/RESPONSIBLE PARTY <br /> INFORMATION: CNECx jr OWNER IS CURRERRY00 FILE wirH EHD 1� <br /> PROPERIYOWNERNAME zzu //�L�r•T�Q/ (RoS)993-379 <br /> v FIRST MI LIST PHONENUMBER <br /> BUSINESS NAME E-MAIL ADDRESS <br /> OWNER HOME ADDRESS <br /> CITY S7/OG�tOr• <br /> J / / sTC� LP9Sz�S <br /> OWNER MAILINGADORES9 <br /> MAILING ADDRESS CITY ! STATE ZIP <br /> -A 9szaS <br /> ❑CORPORATION ysf INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT "-"- ' .EAN _WATER QUALITY_HW PIPELINE INVESTIGATION_LOP_ <br /> FACILITY ID# INV# ArrnUUTI ASBIGNEG EMPLOYEE LEAD AGENCY:EHDRWQCBDTSC_EPA <br /> txo77oti\ � ,C)3 e�ssc�» �oKwRy <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PR ECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No 2[ <br /> IS THIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES No ❑ <br /> BUSINESSIFACILRYISITEIPROJECT NAME t ,y <br /> SITE ADDRESS I PROJECT LOCATION �f SUITE# BUSINESS PHONE <br /> /OyYt <br /> CITY STATE LP <br /> S'p'a cG-'fo.+ eA 95y7-02 <br /> BOARD OF SUPERVISOR DISTRICT q LOCATION CODE / KEY1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPwOML) <br /> MAILING ADDRESS CRY STATE ZIP <br /> SIC CODE APN# COMMENT: <br /> to 3- Ito- oS 11 <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESS NAME -ry SOuiCG �/4 �pJ���C• /'�1 ATTENTION:ORCARE OF (OPT/ONAL) <br /> MAILING ADDRESS 9yY hclou��M2 /cL1. S ` I I (PHONSE <br /> o)272-r/J-UU <br /> CITY STATE LP <br /> G.STT zea//e CA 9s9Y9 <br /> ACCOUNT ADDRESS TO SEND FEES AND CHARGES: OWNER FACILITY/BUSINESS❑ THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: I,the undersigned Applicant,Certify that 1 am the Owner,Operator,Autboricad Agen4 or Responsible Party and I aclolawledge that all P£IORTFEES, <br /> PEN TLFs,ENFORC£Atew CRdRO£S and/or Hounr CH,,RCES associated with this project will be billed to me at the add revs identified above as the ACCOUATAUDR£4s far this site. 1 also certify that all <br /> information provided on this application is true and correct:and that all regWated ettivides will be performed in accordance with all applicable SAN JOAQUIN COUMV ORDINANCE CODES and/or <br /> STANDARDS and STATE and/or FEDERAL Laws and REGULATIONS. As the uadersigned Owner,Operatar,Authe i adAgeny ar Respmrsible P r y for the project located above under facility/sire add revs,1 <br /> hereby authorize the release of any and all results,reports,and other environmental assessment infornsatlon to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as aeon as it is available <br /> and at the same time it is provided to me or my representative <br /> APPLICANT NAME(PLEAS E PRINT) SIGNATURE <br /> TITLE S->~a�f' gefeh�:r�' TMID# 77-Oy669Set <br /> APPROVEDBY DATE ACCODNTINO OFFICE PROCESSING COMPLETED BY DATE <br /> SITE,MITIGA ON AMOUNT PAID DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# RECEIVED BY WORN PIAN PE <br /> 'J <br /> FEE:A 9 ✓ / <br />