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San Joaquin County Environmental Health Department <br /> Tf N GREENFORM <br /> DATE MASTER FILE RECORD INFORMATION MFR SITE MITIGATION&LOP <br /> ��� `� UNIT IV <br /> NO OXTr 0"_IDR CABER <br /> CNECNtE OWNER Cu rSErnLYaNNLeww EHD EJ <br /> OWNER FILL:COMPLETE THEFOLLOW/NG PROPERTYOWNER INFORMATION.' ( ) <br /> PROPERIYOwNEa NAME PNONENUMBER <br /> MI est <br /> FM EawLAooRE11 <br /> BmNesBNaME G0 5}C D Whq l e s le <br /> Owner Homo Addreae <br /> STATE 7 F <br /> CRY0 <br /> Owner Mailing Mailing Address q ci I A0 <br /> k �f�v <br /> Mailing Address City 1 Ir Stffie 1 yP $ C`�y <br /> , SSa vAln <br /> �( INOMOURL❑ PARIMERMIIP❑ <br /> FWAGIDICY❑ OTM�ElQOgppRATpMLy <br /> SRH MRNMITON_ENYIEONI®rRAI ASSESSMENT— <br /> VOLIAWARY CLEANUP_WATPA OUALT/_HW PIPELINE INY11710ATION_LOP <br /> FACIIfIV IDR INVR AccouNr lO <br /> PRWROR A8IIONEO ErPLovEE LAAO AOENen END—RWQCB_DTHC._EPA_ <br /> FACILITY FILE COM)LETETHEFOLLOW/NG BUSINESS I FACILITY I SITE INFORMATION. <br /> IS this a NEW Business LOCATION not preVNluBly regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YES L] No 13 <br /> YES [:] No 13 <br /> Is this an EmsTING Business LOCATION but a NEW TYPE of regulated Business? <br /> BU91NF88IFAGlmISrtENNME P Q ' (�� <br /> l/ T SURER BUMNEBe PIpNE <br /> sITEAtwREsa gal I.I d ganl'e,15 Sh^e,Lk <br /> Cm (STr ZIP q l <br /> BOAf1OOFSurePwBOROMTRIci LDCATIOri CODE <br /> Keri KEY2 <br /> ANenlvn:DrCare Of(aPNpndl) <br /> Malang Addree s eDIFFERENTTrom Fac l!*Addrem <br /> STATE LP <br /> Melling Address City <br /> SIC Cole <br /> APNR C01AEF1C <br /> /eteif Billie Party isdiflerentfremPrOperty owner crFacility operator ldentlNedstwve. <br /> THIRD PARTY BILLING INia COMPg Amorltlon:nrCara Of(OPDOnd) <br /> BUBINEBBNAME KI ele, <br /> NE <br /> MallingAddraea 1) "16 <br /> �17 – <br /> L , ,` LI`i <br /> STATE Zip <br /> Fs <br /> Cm <br /> '�N�n2 <br /> OWNER FACILITY/BUSINESS TMRO PARTY BILLING <br /> for fees and chargee <br /> operator,or Authorized ARent of Mb Bmineas,end 1 admowledge that oU PZaMTFEE$ <br /> A WLEOGMENi: 1,Mr undersigned AppfMent,eertify Mat 1 am roe Owna, <br /> pENU.TLEs,ENFOac£,1IF.TT CNAAGfS vvd/or ROrIALYCHa a ms oriatsd with Mb aplra w11 be billed w me at Me address idevtificd above m roe A UNrAUDRE35 for rids site. 1 also certify Mel <br /> Ihertb euroorbe roe rdeme of <br /> a1 information provided C Hut epPgeafiou h true sod correct;end Mei aU E gammd Bed seine ora rot of roe property located iarroe appsable S�J add ices,OI y rdivvnse Cod.an or <br /> Standards and STATE and/or FEDEM Laws and Rrgsdetiom. As the undera ved owner,op g <br /> any and ov wulb and environmental assnsmmt information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT m soon m it u eva1a61e and et Me same time it s <br /> provided to me or my representative- — <br /> SIOIUTURF�ir�// <br /> APPLICANTKn!FF <br /> NAME(PLEASEPRINf) �tA– nl�'k TAX IDR <br /> YIQ'E"J�DdeAoDATE OF PAYMEM PAYM <br />