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GA <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> ( DATE o��� ��/�3 MASTER FILE RECORD INFORMATION"MFR" GREENFORM <br /> SITE MITIGATION&LOP <br /> SHAD50AREA8FOR EHD UBEONLY OWNER IDSL CABS# UNIT IV <br /> OWNER FILE:COMPLETE PROPERTY OWNERI RESPON6IBLE PARTY INFORMATION: CHEGR/FOwAERisCuRR>ArrcvICY FILE wiry E H D <br /> PROPERTY OWNER NAME <br /> 3 FIRSr MI UST PHONENUMBER <br /> BUSINESS NAME E-MAti.A0DREss <br /> `�-El���cn Znc. <br /> OWNER HOME ADDRESS <br /> I CRY STATE 7jP <br /> OWNER MAILING ADDRESS D 6tx –A` 11 <br /> j MAILING ADDRESS CITY STATE ZIP <br /> IJ <br /> N <br /> CORPORATION ❑INDIVIDUAL ❑PARTNERSHIP ❑GOVERNMENT AGENCY ❑RESPONSIBLE PARTY ❑OTHER <br /> SITE MITIGATION 'l ENVIRONMENTAL ASSESSMENT—VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> FACILITY IDB INV# AccOUNTID PRIVRON ASSIDNEDEMPLOYEE LEADAGENOY:EHD RWQCB_DTSO_EPA_ <br /> 013 lkimtledrnot <br /> FACILITY FILE:COMPLETE BUSINESS/SITE/PROJECT INFORMATION: <br /> IS THIS A NEW PROJECT LOCATION NOT PREVIOUSLY REGULATED BY THE ENVIRONMENTAL HEALTH DEPARTMENT? YES ❑ No GK <br /> ISTHIS AN EXISTING PROJECT LOCATION,BUT A NEW SCOPE OF WORK? YES R No ❑ <br /> BUSINESSIFAcILITYISITEIPRoJECTNAME r7`Elevtii O X117 <br /> SITE ADDRESS/PROJECT LOCATION �.�A5 ('otenil2 OGr 'doul/e "d SUIEfll BUSINESS PHONE <br /> CRY <br /> STATES H J 71P 95,?0,q <br /> BOARD OF SUPERVISOR DISTRICT ,Jro L�O+OATION CODE KEY'1 KEY2 <br /> MAILING ADDRESS,IF DIFFERENT FROM FACILITY ADDRESS ATTENTION:ORCARE OF(OPTIONAL.) <br /> MAILING ADDRESS CRY SATE 'Zip <br /> SIC CODE APN# 1�� d21 D 0(a COMMENT: <br /> THIRD PARTY BILLING INFO:COMPLETE IF BILLING PARTY IS DIFFERENT FROM PROPERTY OWNER OR RESPONSIBLE PARTY IDENTIFIED ABOVE. <br /> BUSINESSNAME �J qq///--l'/,�Ln �,.„Oq ' '�jan,llLcs �n�ATTENTION:ORCAIiE OF(oPT/Ok�QLL) <br /> i MAuJNo ADDRESS dV/ / „tl 'dtt &d, 6G/�IIk /IDOJlU rt. w•-I/ AHONE vo0 <br /> CITY dG eho U/lul//VW STATE ZJP <br /> ACCOUNTAODRESSTOSENDFEES AND CHARGES: OWNER❑ FACIUTYIBUSINESS❑ THIRD PARTYBILLING0111 <br /> BILLING AND COAIPIIANGR ACIcNOwt.r:DGAtERT. 1,tilt undersigned Applicant,certify that I am the Owner,Operator,Authorized Agee,or Ropouslble Par9+and I adsuowledge that all rwitTFEBT, <br /> PEM'IL7Z&%EATONCEIIENI C&w6E.T andfor HOmu.i'CR.+kcIF_c associated with this project vTiN be billed tame at the address ideatiRed above as the ACICOVATADARET.S for this site. ►also certify that an <br /> information provided on this application Is true and correct;and that all regulated activities will be performed in accardance with all applicable SAN JOAQUIN COUNIV ORniNANCR CODIS and/or <br /> STANDARDS and STATE and/or t-DERAL Limos and REGULATIONS.As the undersigned Oarrer,Operator,iLuhoiftedAgenl,or Havponsibk Parry for the project baled above under facllily/site address,I <br /> belcby authorize the release of ally and all results,reports,and other environmeatal assessment information to SAN JOAQ LINTY RNWRONMENTAL IT[ALTR DFPARTMENr as soon-it is araileble <br /> and at the scone Lillie it is provided tome or my repmenbetive. ' <br /> APPLICANT NAME(PLEASE PRINT)/1 �1 e b M±tn ,e4 SIGNATURE <br /> TITLE �4&tl4i. / tCLr .�/, 17.9vieJ! ��1 TAX IDN <br /> EAFPAOV,F0 BY f w T'�(/ W'DAA� r�' cCC� IIIA---][A:,.....CE PROCESSING COMPLETED BY DATE <br /> IGATION AMOUNTPAID DATE OF PAYIAENT PAYMENT TYPE RECEIPT# CNECK# RECEIVED BY <br /> l <br />