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0 <br /> San Joaquin County Environmental Health Department <br /> DATE �� MASTER FILE RECORD INFORMATION"MFR9y GREEN FORM <br /> rnt.11 tri SITE MITIGATION& LOP <br /> h39tr.K, UNIT IV <br /> S EHO ONLY OWNER IDM 7 CASED <br /> S�-oo 6y Ia- <br /> OWNER FILE:COMPLETE THEFOLL OWING PROPERTY OWNER INFORMA rlow CHEM lFO/W'NER CURa &Y"psLERom ENDd <br /> PROpearYOWNERNALY (209) ver- <br /> First MI Last PHONENUM9ER <br /> BWINEw NAME —r E-MAILADDRE88 <br /> S.. TOp Luh (eG1+,f — �' (✓,.4 eH� <br /> Owner Home Address <br /> /bio E4:f Ze/fa'+ Ar/r. <br /> CRy STATE zip <br /> Owner Meiling Address <br /> Mailing Address City Stabs zip <br /> CORPORATION❑ INDIVIDUAL❑ PARTNERSHIP❑ FED AGENCY❑ OTHER❑ <br /> SRE MITIGATION_ENVIRONMENTAL ASSESSMENT_VO ARY CLEANUP_WATER QUALITY_HW PIPRUNE INVESTIGATION_LOP_ <br /> FAOILITYID# INY# ACCOUNTIO P ROI AseIONED EMPLOYEE LEAD AGENCY:EHD_RWOCB OTSO_EPA_ <br /> �� 2 tI7Jh 3�D8S OS3 bTi7 �' 1 <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY/SITE INFORMATION.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? yes ❑ No er <br /> Is this an EXISTING Business LOCATION beta NEW TYPE of regulated Business? YES ❑ No <br /> BU91NE99IFAcnaTY/Sn NAME <br /> a v+mom/ Coun na�� <br /> Sne ADDRESS SUITE# BU91NINSPHONE <br /> Cm STATE ZM <br /> 57fo.,4710.„ 64 9sa/5- <br /> BOARD OF SUPERVISORDISTRUCT LOCATION CODE HEYi REY2 <br /> Mallireg Add reAa I/OIFFERENThDtrl FacAftyAddress Attention:orCare Of(opbnrsall <br /> Mailing Address City STATE zip <br /> SIC CODE APNII COMMENT: <br /> /D 3//006 <br /> THIRo PARTY BILLING INFO: Complete if Billing Party is different from Property Owner orFaclllty Operator identified above. <br /> BusmEss NAME / // �T^^ Attention:orCare Of(optional/ <br /> /ITE SdoleG Urap <br /> Mailing Address PHONE <br /> 9vY <br /> Cltt // STATE zip <br /> 6N 5. 6,411 C <br /> AGCQLMTAauaess forfees and charges OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING ND COMPLIANCE ACRNOWLCDGAIERT: I,the undersigned Applicant certify that I am the O.aer,UPe..to,.or A.M.Nized AV t oRhis Basiness,a c ge that AI/'£RANT Fens, <br /> PcNALriEs,EN£oRCF.1IEAT f'/UtRG£s and/or HOURLY CuAGES associated 1YIth[Ills Operation will be billed to me al Ella address IdenNBed above as[Ile A r.Y.MOuvrADDREiS for this Site. 1 also certify that <br /> at]information p...Weil an this application is tree and correct;and ib at all regulnled aetlNlles srlll be performed In accordance 111th all APPIIeable SAN JOAQUIN COUNTY Ordinance Codes and/or <br /> Sland:Wsand SrATE:lIe/or FEDEM Lnwsnnd Regulations. As the undersigned enter,operator,or agent ofthe Property located at the above facility/siteaddress,I hereby mnhnrize IIIc release of <br /> any and all resides and environmental assesatneld information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative_ <br /> APPLICANT NAME(PLEASE PRINT) Alla r+ too , SIGNATURE F1� <br /> TITLE TAX ID p <br /> Approved By Dab AccoamUxIg Omco ProcemIng Completed By Onto L <br /> SITE MRIGATIQN AMOUNT PAm DATE OF PAYMENT PAYMENT TYPE RECEIPT# CHECK# R/!/��a VVEED BY WORNPLANPE <br /> ( Y IjY�—/, -5--1 <br />