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DATE (b '1 San JOaquln County Environ <br /> MASTER FILE mental Health De <br /> RECORD INFORMATION "'I <br /> pa�tment <br /> f'MRIIIR FILE'99-* L caMER Ips /d 1 / [–T� GREEN FORM <br /> A`tfFOLLOiy/NG P '7 JCS CASE �D�O �3�71 SITE MITIGATION 8, Lop <br /> PROPERn.pwW�NAME ROPERTY <br /> OWNER✓NFORAwrroN• " UNIT IV <br /> BUeINEu NAME First A"OWNER CORREwgroA""Wyt�END <br /> 1 M/ <br /> OwnerHwna �treW�sf� Q.•,,.,. _ _ Last (q2SJ) 4+9 - IOZ3 <br /> Adtlnq • t f 1 YCJ(K.O�� PNONe NDMaeR <br /> •L'-MAIL AoDREsa <br /> city Oen Q�'IrtWO✓ <br /> 0.me✓icr,com <br /> Owner Malting Addraaa <br /> 1_•v• <br /> Msox 4Bg eillnp Add City STATE ZIP <br /> CORPORATION S44 t� ZI <br /> INDIVIDUAL� P <br /> PARrNERgNIv❑ <br /> 40 <br /> 1:111RyL(J <br /> $�AAIYNIATION lHVIRONep�� FEO aoENCY❑ <br /> 11 FACILRTIDI '-' ~-afT voLUNTARY C{(utUP ORI0 <br /> I Yrs ACCOIMri ID P t9AYRR QUAu y_tMw PFFeLINe 1 <br /> �2Qq ROr AaaloNeD EMPLDrEe �RSnIAMN—LOP <br /> LEADAGENOY:END Rw4� <br /> FACILITY FILE CAMPLB7F7HEFOLLOriTAGgU$INESS/FACILITY/SITE/NFovAoanoH —DTSC_EPA <br /> IS Nig aNEW BUa1R866 La-..tTIDN not preWDUaiy renRlatetl by Ula ENVIRONMENTAL FIEALTH UEPARTMENT7 <br /> Is this an EXISTING Business LOCATION lNlte N9YjyPE ofregulated Business? YES ❑ No <br /> SuLNFDNFADarrYlsne Nue YES Q No O <br /> a1 D Ylamtc5 o-rs <br /> SRMADDRMS <br /> 2�7 Covral �otl7r� fit, swrna BUSIN P e <br /> CITY . (SSo <br /> $TA¢ zip 0 5 1� <br /> BaRoaBliBnso.Dar.Rscr LocATpN CDOE Key `/.Arr. <br /> KPI <br /> MaBRq Addraw IrAv7FRF)VTMwn Fm*Addseev <br /> 11,v Attention:aCara Of(dpygyo <br /> Mailing Adds Cly 1t� �I_ �• N1��IIV�C.. SrAIPFTE ZIP <br /> Lt- <br /> AP325-7$ <br /> slCCtwAPI �: <br /> THIRD PARTY StLuma INFO: Canplete if Rift Party!s different from Property Owner OrFacllity Operator identilred above. <br /> GUSINEaa N41E <br /> AfbMlon:trCen O/ <br /> rPPadn.9 <br /> o�I Ineerinr ly)c. <br /> Mailing Addrasa -1110 PCU't�LL. LAw 1 SIA kI PNoNe <br /> l l C �510 v36. 8500 <br /> QTT pa� �/t 16njgr-C, STATE �r't( A_ 1 ZIP +t0a1 <br /> Arm AYr-<vsvc._for fees ane charges u�� NESS Q <br /> THIRD PARTY BILLMG <br /> RI, III.All C^v°'".•[T ACNNOwt.mGw FST[ I,lM1e unden;Np h sed Apem of this Basrness,end 1 ueknowkdee Not All PERM FEe.Y, <br /> Pengllorm fv'p-A¢ TCHn s appnd tion a v[r CXd cvsr 91, _ id<ndfied eboY<ss cheAa OV,VfArmeecrforthie sik. l elmcertify the, <br /> all m6rcaNm pe.ided on this Appliufion u vee ad casae ah. 7 <br /> Standards Aad S-AP-zos or FEn[nAL Laws and Rephntt r Vut encs with all Applicable SAN JOADWN COUNT,Ordinance CodesAndo: <br /> mated at the above rscinty/site address,I h.......thnrlae the r<kne of <br /> em and.n rasa w.d environmental auusrrms Ink-avti=�IN JOAQUIh'COUNfY er.....,•,.,.._ <br /> prosided W iPe:r r H DEPARTMENT as soon As it u available sod at the same Nme it is <br /> revraenlative. \ `' `'rr A <br /> APPLICANT HANE IPLuaePalNsl {,15� T`-1iAr-N+•' SIGNATURE <br /> TITLE V\ubgymId.Qm* �NITNe�iY1Q.Q�1'1t1�'Ilr[, TAxID# <br /> ApprwadS Dab Aaoorn OIRoa Prmaaal Cate labd Gab <br /> DATE OFPAr PAYMENTTYPE RECEIPTdi <br /> SITE MITIGATION AMOUNT PAID <br /> FEE:3 ^^ CNECNa RECEIIVE'D BY Wa�TmtppuN PE <br /> �Y f 77 ��1'� P•/•� 9 <br /> �C° <br />