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San JL.aquin County Environmental Health L ,,artment <br /> DATE MASTER FILE RECORD INFORMATION `aMFR" GREENFORM <br /> MAI 112012 SITE MITIGATION & LOP <br /> I <br /> UNIT IV <br /> sHgoeO AREAS FOR END USE OrvcV <br /> OWNER IDM CASE <br /> OWNER FILE : COMPLETE THEFOLLOW/NG PROPERTY OWNER AfFORMAT/oN: cHecK/F OWNER cuxwEurLvournEwirs EHD <br /> PROPERTYOWNERNAME DAV tl? ({ 0oJ6R <br /> FirstMI Last PHONENUMBER <br /> BuSINESSNAME E-MAIL ADDRESS <br /> CA FVFL <br /> Owner Home Address <br /> 5ell Yrnivacto VA & te6o 9040 <br /> city STATE ZIP <br /> GfAL Nur c ilz� lc CA 94s510 <br /> Owner Melling Address <br /> fAtnt AS AYOVL- <br /> Mailing Address City State Zip <br /> CORPORATION INDIVIDUAL ❑ PARTNERSHIP El FEO AGENCY El OTHER ❑ <br /> SITE MITIGATION _ ENVIRONMENTAL ASSESSMENT _ VOLUNTARY CLEANUP _ WATER QUALITY _ HW PIPELINE INVESTIGATION _ LOP <br /> FACILITYID # INV# AccoUNTID PR ## RO # ASSIGNED EMPLOYEE LEAD AGENCY: EHD_RWQCB _ DISC _ EPA_ <br /> FACILITYFILE COMPLETE THEFOLLOW/NG BUSINESS I FACILITY ISITE /NFORMAROW ��ff <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES ElNO ,By <br /> Is this an EXISTING Business LOCATION but a NEW TYPE of regulated Business? YES ❑ No <br /> BUSINE991FADILIWISITENAME Fgen1Bk SyFLL SE,QVIcE S7A'rfon/ <br /> SITE ADDRESS SUITE # BUSINESSPHONE <br /> 2575 CouNT2 CL t/ b 3G VO <br /> CITY STATE ZIP <br /> ,$ T" 0 c Kro #%) CFF 962 o y <br /> BOARD OF SUPERVISOR DISTRICT LOCATION CODE KEY1 KGV2 <br /> Melling Addraaa KCIFFERENrfrom FaclMyAddYwae Attention: co-Care Of /apf l nal) <br /> /0 569 7RR045 Cro1v71; R OR t ✓; S✓ Ire <br /> Melling Address City STATE ZIP <br /> Ry- N cF-e o Gr;tzpo ✓if CfF 96ba't� <br /> SICCODE APN # COMMENT: <br /> THIRo PARTY BILLING INFO! Complete if Billing Party is different from Property Owner our-Facility Operator identified above. <br /> BUSINESS NAME C d A/ E Sro y it - (Z st VERs /Esso cf w 778 y Attention: orcare Of topf/om q <br /> R RFZ " r�L �a <br /> Mailing Address <br /> PHONE <br /> / 0 qb9 T/Z 140E LENTf fz pkI ✓(_ T ✓ IrE ! � '� q /b � of) cl Ploo <br /> Cm STATE R* (VCH0 caiec) d A✓A CZ%Sb � d <br /> AccauATAonness forfees and chargee OWNER FACILITY/BUSINESS IRD PARTY BILLIN <br /> i <br /> BILLING AND CONIPLIANCL AEKNOvNR EDGNmm': 1, the undersigned Applicant, ceI'tif}that I am the Omner, Oneraftn, or Arnhatizwl Agent of this Business, and 1 acknowledge that all PERIITT FEES, <br /> PE.N:ALT/ES, E.NEORCEvE:NTCHA S <br /> and/or Hot RI.i' CHARG associated with this opera[inn will he billed tome at the address identified above as the AC'coTiv'rA reorss for this site. 1 also certify that <br /> nil information provided on this application is true and correct; and that all regulated activities will be performed in accordance with all applicable SAN JOAQUIN COUNIN OF Codes and/nr <br /> 11 Standards and SIA ]t: And/or FECERAL Laws and Regulations. As the undersigned mvnei , operator, or agent of the property located at the above facilih/site address, 1 hereby authorize the release of <br /> i� any and a6 results and environmental assessment information to SAN Jl1AQUIN COUNTY CNVIRONrvICN'1'AL HEALTH DEPARTMENT as soon as i is is vailaL lilt and xt tiw some time if is <br /> provided to me or my reprcsentafive. /�/ <br /> APPLICANT NAME (PLEg9E PRINT) LAR12Y 5` ) L \/A SIGNATURE <br /> TITLE pRtlJ � cr Mat� A: FitEI\ TAX ID # <br /> 1 Approved By I Dale ACcoansng Office Processing Completed By Date <br /> I' SITE MITIGATION AMOUNT PAID DATE OF PgVMENT PAYMENT TYPE RECEIPT # CHECK # REOEIVEO BY WORN PLAN PE <br /> FEE: III <br />