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San Joaquin County Environmental Health Department <br /> DATE /Zot MASTER FILE RECORD INFORMATION "MFR" GREENFORM <br /> SITE MITIGATION & LOP <br /> SHADEDAeEAe FOA EHD USE ONLY owNER IDN CAeEN UNIT IV <br /> OWNER FILE:COMPLETE THHEFOLLOW/NG PROPERTY OWNER/NFORMAT/ON. (/CHLECCKIF OWNER CHRRENnvoNFaewnH ENDQ <br /> PROPERTYONHERNAME FRED —rA0OT3lnS <br /> (0) '}lot- (¢Goo <br /> First MI Last PHONENUMaas <br /> BUSINEWI NAME " E R.Asonsas <br /> 4O <br /> �fArtOND O1DS -n �QCObLAZe_p141A+ondICOVRy• <br /> Owner Home Address I O SO ;� Y/^ ^ ,Q IN V,D CIDn^ <br /> City r�Vv` <br /> D�`�,^` STATE�{•�n^ LP 95-z DS-- <br /> Owner Melling Address <br /> Mailing Address City State Zip <br /> CORPORATIOIN/K INDNIDUAL❑ PAeTNERBHIP❑ FEDAOEI'4Y❑ OTNER❑ <br /> SITE MITIGATION_ENVIRONMENTAL ASSESSMENT_VOLUNTARY CLEANUP_WATER QUALITY_HW PIPELINE INVESTIGATION_LOP <br /> Fq mID# INVN ;Accsoularr D PH 0# Assn"ED EMPLorEE LEAD AGENCY:EHD_RWQCB_OTSC_EPA_ <br /> 9 <br /> FACILITYFILE COMPLETETHEFOLLOW/NG BUSINESS/FACILITY/SITE AtFORMAT/ON.' <br /> Is this a NEW Business LOCATION not previously regulated by the ENVIRONMENTAL HEALTH DEPARTMENT? YEs ❑ No 19 <br /> Is this an EXISTING Business LOCATION I A a NEW TYPE of regulated Business? YEE ❑ No PR <br /> BU8INEBWFACILT'ISBE NAME 'T T AJ-'t <br /> SnEADDesss cJ IDS-0 <br /> O S-^ SUREN 13UWNMPMNE <br /> U LAr�a a AIYj GG 'J <br /> Car �el�TO� STATE zip 9 s Z o S- <br /> BOARD OF SUPERVISOR DBmIOT / LOCATIONCODE KEYI KEY2 <br /> Melling Address KD/FFERENTIrom Fal cX1yAddreas Attention:oFCare Of(opHona/J <br /> Mailing Address City STATE zip <br /> SICOODE APN N �f _�� V Cf COMMEM: <br /> THIRD PARTY BILLING INFO' Complete if Billing Party its different from Property Owner orFBCIII y�s,' <br /> Operator identifiedabove. <br /> Sunniness NAME /1 TTI /t S, '+Oe– l�l e-g Attention:oYCare Of(optlane/J <br /> Mailing Address - 111 -7 LvNEPHONE <br /> !�-ASM -r4-t/:=�1u E 20 - 579 - 2 2 2 1 <br /> Cm STATE� ,s Zro s. 3 s./ <br /> Yo DESTv (-fi- <br /> AGGODMAaaffMS for fees and Chargee OWNER FACILITY/BUSINESS THIRD PARTY BILLING <br /> BILLING AND COMPLIANCE ACKNOWLEDGMENT: 1,the undersigned Applicant,certify thn/I am the(honer,Operoroq or AulGorited AgeMof this Business,and I acknowledge that all PERARTFEES, <br /> PENALnET,ENFORCEN£NTCHARoFA and/or HOUN.YCHARGET associated with this operation will be billed tome at the address identified above as the ACCOOM'ADDRESS for this site. 1 also certify that <br /> all information provided on this application is true and correct;and that all regulated activities will be performed in accordance with all applicable SAN JOAQNN COUNTY Ordinance Codes and/or <br /> Standards and STATE and/or FEDERAL Laws and Regulations.As the undersigned owner,operator,or agent of the properly located at the ihave facility/site address,I hereby authorize the release of <br /> any and all results and environmental assessment information to SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN 'NT as soon as it is available and at the same time it is <br /> provided to me or my representative. T I <br /> APPLICANT NAME(PLEAw PRIN) <br /> , SIwuTURE <br /> TIE RATECT d-t4NAhE2 TAX ID# �IAl ,1�3gq�QA <br /> Approved By Date Aoaculrang Officar,Procanning Cpm lewd By <br /> h. Ll f Z— <br /> SITEMITIGATION AMOUNTPAID DATE OF PAYMENT PAYMENTTYPE RECEIPTN CHECK# RECENED BY W00.K PgWl PE <br /> FEE:$ <br />