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San Joaquin County Environmental Health Department <br /> It ed GREENFORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> rHo�a=oat. DWNEaID. OW ooal3.31� �^°�• SR�o��o�o UNIT IV <br /> CNECNM OWNER CD,eREATtYosntew ro EHD <br /> OwNIRFILE:COMrcMn4EFOLLOWNGPROPERTYOWNER/NFORMA770N: ( ) <br /> PROPat,,OWNEIt NAME <br /> Frsl <br /> MI Last PNDNENUNeEn <br /> E-YYLA[Id1E8a <br /> BustNaaNatte C,-O5}cF) LJI��12s (i <br /> Owner Home Addraea <br /> STATE Zip <br /> City <br /> Owner Melling Acidneaa 90;1 I �k Dc�v � <br /> I- L Stets LP <br /> Malling Address city \ S S 0. V N" W A $ �Z <br /> .--�/ PARfNERaHIP❑ FIN)" GY❑ OSNER❑ <br /> CONPOMIM)NLyI I11aMOWL❑ <br /> Srm MMeATION_ENVIBONMEWALL ANINSUA Nr—VOLUNTARY CLsANuP_WATER aumm—ION PIPIUM liqua eATION_LOP_ <br /> FACIu1Y ID• INVR AccouNrlO PR Oi AEMONLTI EMPLOYEE LrAn motcY:EHD_.X_RWOCB_one_EPA_ <br /> �,/7b � �4S�ib OS3�7y -bl�Nwy <br /> FACILITYFILE COMPLEnFTNEFOLcowAuulIRINESSIFACILITY) <br /> SITE/nAFORManoN: <br /> Is this a NEW Business LocAnoN not Previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? Yes ❑ No la <br /> Is this an Eq$nN0 Business LOCATION but a NEW TYPE of regulated Business? <br /> Yes ❑ No U, <br /> BUEINEa91FAminYASRENAAIE /' C�(N <br /> l/� / SunEa Bua1NE9a PNONE <br /> srtEAoaPEsa .z LIpto Do,n,dc, S1r''_ <br /> Cm C? LP <br /> (,TE gS33 <br /> til G.n�-C� 'rC� <br /> BtAMM UPetWac)fto icrt <br /> S LacATro.co se 4/ RErt Nev2 <br /> Aaengon:rrrCeM Of(aPabrral) <br /> Melling Addram No/FFERENTfram FacWAddreas <br /> STATE LP <br /> Melling Addraaa City <br /> SIC CDDE APNO CalatEllf: <br /> 11 p41- 53o - v/ <br /> TUHiRD PARYY BLLL11dp IN Po: Comp/eleif Billing Party is dHferentiromProperty Own err oerFFeail yOpere � Jntil/edebove. <br /> �CaBWINERaNAME K12tn�'e��-� -TC <br /> Melling Addrem /ij A-1,.1AI CjJ\�. ` /� PIbNE I) LI �, <br /> CfrYCV 41n/�� ^ STATE g <br /> 2G18 17.b <br /> 1WRo PARTY BLuNe <br /> forTees and chargee OWNER FACIIITYBDSINESS <br /> 13,UMG ALMLs Aar NL OGNENr: 1,Me un eatoneded with n,,certify <br /> Mat 1 am lee owns,Operator,or Authonvd Agent of Mi+gminev,and I eclmowlthin that an a cenTFtEs, <br /> Pn zns,ENFORCF-NENTCNARGa andlor-u— in avodand with Ma operation Will be billed m meet Me address identified above as Mee SM JO QMN c r for Mu alta 1 also certify Mer <br /> an informedon provided on this appticatien u"a and correct;end Mvt aU regviated actiP Nes ,iU bee rformedP P c�eace d at an applicable ty to addRN Ci hereby <br /> Ord �c toed due of <br /> Standards and STATE and/or RD£ Lawn and Regulndom.Aa Me undersigned owveq operator,ore cat of Me o e located al the above(nciii /nih addrev, y au <br /> avy and au r Wa and evvirovmmhl anmmenf information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT m soon as it u ovadable and at Me same fine it u <br /> provided tome or my rcprrsrntative <br /> APPLICANT NAME(PLEASE PRIW) �,�•,� (llrt.iY.' TAXIDNP�itiii - <br /> TAIL D p <br /> TITLE ate Y 13 <br /> raved aeb Account! Otdca Prcoml C Wd <br /> MILT <br /> SITEMm"TIDN ANOUNTPAID DATEDFPAYNENT PAYMENTTYPE ReeQPre CNEcrf� RECFIV®BY WORN PLANPE <br /> FEE:$ ��� -3 y-zz-i3 �-I C'}oz83 �'���' <br />